Wendreth Court

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We found evidence that following an incident, accident or concern, actions were taken including reporting to the right people, completing incident reports and sharing lessons learnt. Staff told us that they felt they could approach management to report concerns and that they would be listened to. We saw evidence that complaints from relatives had been investigated and they had been provided with an update and feedback. People told us that staff were approachable and gave us examples of when feedback had been used to improve quality of care. People we spoke to did not have any issues with safety. All were happy with the way staff went about helping them with mobility and personal care. There were enough staff with the right skills.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us ‘The staff are good, we get checked on regularly and the bell gets answered quickly’. One relative told us 'I always feel I could talk to someone immediately if I am concerned.’ Another relative told us if there is an issue they go straight to the registered manager who acts on it straight away. Relatives told us they felt reassured with the care provided and gave examples of concerns being addressed and resolved by staff. One person raised concerns about supplies of continence products but the registered manager was aware of the concerns and able to evidence available stock and the orders that had been made. Another relative had concerns regarding provision of necessary equipment for their family member, we could see that the registered manager had taken action and showed us that appropriate referrals had been made.

Staff told us they found the registered manager approachable. The registered manager advised that following incidents or accidents they complete an analysis which they then discuss with staff in meetings and share learning. Staff told us there was a positive learning culture at the service which was aided by good communication within the team. For example, 1 staff member told us, '[Staff] will all say if something is not right, and we would make changes immediately to make it better.' Other staff said they benefited from daily handovers and staff meetings to share important information within the team.

We found evidence that following an incident, accident or concern, appropriate action had been taken including reporting to the right people, completing incident reports and sharing lessons learnt. Records showed there were clear processes and systems in place to monitor incidents and ensure actions were taken. The registered manager had implemented daily head of department meetings, and daily clinical meetings at the care home. This allowed all aspects of the service to be discussed, and any matters relating to safety, near misses or lessons learned to be reviewed on a regular basis. We observed how the registered manager used these meetings to remain continually updated, and we saw how they offered direction and supervision to staff, as well as prompting staff to reflect and learn lessons from occurrences and events. Daily shift handovers took place, and staff told us they were beneficial, and allowed them to pass on important information, as well as current information, to the next team to promote safety.

Relatives told us that during the admission process the registered manager had lots of conversations with their family member and they were involved in developing their care plan. People told us they felt safe and 1 person said, ‘I needed to see the GP once and that was arranged quickly’. One relative raised concerns about their family member being cared for in bed due to lack of suitable equipment. The registered manager could evidence referrals made to the Occupational Therapist and Physiotherapist to consider equipment for safe transfers.

Staff told us they felt safe systems were in place to support people and their admission to the service. Staff told us they had access to personalised information relating to people to assist their transition, and to promote their safety. Staff said they ask the person what was important to them, and what they would like support with, but also told us care plans were in place to provide information on needs, risks and risk reducing measures. Staff told us care plans were reviewed and updated regularly, and information relating to changing needs were also discussed during handover. The registered manager told us that when someone moved into the home, staff spent time with them to gather information about their culture and routines and try to make their environment familiar with personal decoration. The registered manager gave examples of health services they link with including the Pharmacist, Dementia Specialist, District Nurse, Dietitian, Falls team, Mental Health team and GP.

We saw feedback from a local authority brokerage officer praising the registered manager for their response to new referrals. However, feedback from partners was limited due to them having minimal involvement with the care home so far.

In addition to the electronic care plans, each person had a paper folder with important information including hospital discharge summaries, local authority assessments and health appointment letters. We saw evidence of pre-admission assessments with information about people's routines and physical and mental health needs. We saw evidence of referrals made in care plans and records of joint working with other teams and hospitals to ensure safe discharge planning. We viewed meeting minutes that recorded staff discussions and information sharing about referrals to other services, people's upcoming health appointments and important updates. The care home has clear and up-to date medication and safeguarding policies in place which provide information on how to safely manage medication following someone's transfer from another service or hospital and when to make referrals to other professionals.

People and their relatives told us they felt safe and knew who to speak to if they didn't. One relative told us they always felt they could talk to someone immediately if they were concerned. Another relative gave us an example of how they raised a concern and how it was managed and resolved appropriately. Everyone we spoke with said they were happy with the way staff supported their mobility and personal care.

The registered manager told us that they ensured staff were aware of safeguarding and whistle-blowing procedures by discussing policies each month during team meetings and as part of the interview and induction process. The registered manager told us that they reviewed every incident during team meetings and refreshed staff knowledge regarding what to identify as abuse. They told us they reviewed incident and accident forms and asked staff for reflective accounts of what they had learnt following an incident. Staff told us they had completed safeguarding training, which was face to face and online, and were confident to raise concerns with the management team. Staff said they felt any concerns raised would be acted upon. For example, 1 staff member told us, 'I have no safeguarding concerns. If I did, I would report them to my senior, deputy or manager. I know I can go higher if needed. We have posters up in key areas, and I have not seen any marks or injuries on any [person] which has made me concerned.' Another staff member said, 'We have speak up information in the [care home] with a telephone number and email address if we need it. I would report anything that made me concerned.' Staff had knowledge of the differing types of abuse which they could encounter in a care home setting, and were confident the management would act upon any matters of concern. Staff had good knowledge of the Mental Capacity Act and its principles and told us they had completed training. Staff were passionate to ensure people were given choices and the ability to make their own decisions where it was possible.

We observed staff responding promptly to call bells, safely administering medication and providing support to people with eating and drinking. We observed staff identifying concerns and taking action. For example, for someone who was feeling unwell staff discussed alternative food and drink options, requested pain medication, informed the registered manager, provided reassurance and discussed potential referrals and reviews required during a staff meeting. We observed staff were mindful of their practice to promote safety and reduce the risk of safeguarding occurrences. This, for example, included knowing which people needed specific assistance to promote their safety but this did not reduce their independence. For example, 1 person required specific staff assistance to ensure their safety when mobilising, however, this was only required in specific areas and staff were aware of this, and ensured the person was confident to continue without their assistance before leaving. Staff were also seen to consider what may hinder people's safety ahead of time, such as where yellow wet floor signs were situated which indicated a wet floor. Staff communicated with one another when people left the service for appointments, or to be with family. This ensured staff were aware of people not being present and what time they could expect them back. Staff were seen to ensure high risk areas were secure, such as access to the laundry area, kitchen, medicines room and sluice. The daily clinical meeting which was held in the afternoons allowed senior staff and the registered manager to discuss any concerns, and for actions to be completed in a timely manner. We saw staff were responsive to the advice given by the registered manager, which allowed regular risk reviews and mitigation to take place.

We reviewed the provider's safeguarding policy which was up-to date with useful contact details. There was also an accessible ‘abuse’ policy for people to access. Incident records included details of actions taken and we saw evidence of sharing lessons learnt with staff. However, we felt there was a concern raised by a family member that should have been discussed with the safeguarding team, which the provider acknowledged. Care plans included Deprivation of Liberty safeguards documentation and Mental Capacity Assessments. The home recorded all restrictions in place for people including key coded doors within the service and 24 hour support from the care team. Records explained when restrictions were necessary to keep people safe and included views of the person and next of kin. However, we found there was conflicting information in care plans regarding people’s capacity and assessments were not always completed fully or up-to date.

Relatives told us how the staff had managed risks for their family members and told us that the staff team knew their family member well. They told us that staff managed to support people's independence while considering the risks. They told us they had input into developing care plans and were informed straight away if anything happened, for example if their family member was admitted to hospital.

When asked about the arrangements in place to manage risk, the registered manager told us the staff team discussed any changes, concerns and appointments for each person during the daily meeting. The registered manager told us they frequently walk around the home to identify any risks and offered support to staff. They told us that monthly analysis of incidents was undertaken to identify any patterns of concern. For example, if someone was at a higher risk of falls they would consider equipment or a referral to the falls team. One senior carer told us that some residents who had capacity chose to lock their doors during the night which was their right to decide and they were aware of the risks. Staff told us they were able to learn about known risks for people by reading care plans and handover discussions. Staff said they ask what support people want, and how they want to receive it. Staff were knowledgeable on actions to take in the event of an incident, and how to report concerns if safety reviews were required. Staff were able to tell us the training they had received to reduce risk, as much as possible, whilst promoting independence. For example, some people wish to have varying timed wellbeing checks at night, staff told us this was clearly documented for the person and reviewed with them.

A range of safety equipment was available at the service. This included sensor mats for people who were at risk of falls and general adaptive equipment to assist with mobility needs, such as wheelchairs, commodes, hoists, bath hoists and adapted weigh scales. Electric profile beds were available and pressure reducing equipment such as mattresses and cushions. The availability of this equipment meant that people had access to risk reducing measures when required, especially if their needs are variable and in response to acute health needs. The calibration and safety checks had been considered for equipment. Staff practice observed demonstrated effective risk management whilst promoting independence and choice. Staff supported people with their mobility, and people were empowered to remain as independent as possible, whilst risk reducing measures were considered. For example, 1 person who had a sensory impairment had requested safety furniture guards for the corners of items such as tables and drawers and this was organised without hesitation by the registered manager to improve safety and increase the confidence of the person.

We saw evidence that people were supported to do the things they want to do even if there were risks. Risk assessments took into account individual needs but we felt some assessments were contradictory and required further information. For example, we felt that there could be clearer, more detailed guidance in some care records regarding allergies, weight monitoring and pressure care. The provider could verbally explain the risks and told us they would take action to update the care records.

People told us there was a cleaner in the home at all times and that domestic staff did a good job. One relative said that one day their family member's room was unclean but then the following day it was very clean and the bed was made.

The registered manager told us that they complete a daily walk around of the home to ensure the environment is safe and to identify any risks. Staff told us that the environment is well maintained with daily housekeeping. They also told us that staff will clean up following any incidents or accidents.

We observed the environment to be safe and clean with nice décor. The care home is a newly built service and all furnishings and fittings were visibly new, appropriate and fit for purpose. There was accessible outdoor space and a choice of communal areas. Equipment was in place for those who needed it. We felt there could have been more dementia friendly features with better use of colours and signs. This is an area the provider had identified, and a dementia specialist has since visited the home. We felt that the call bell volume needed to be turned down, especially so not to disturb residents at night. We also felt that external lighting should be available at any time. The provider has addressed both these suggestions since our assessment. The environment had safe measures in place to ensure the security of the building, people and staff. This included pin access to specific areas, CCTV and modern call bell assistance. We found high risk areas, such as the laundry and kitchen, were secure. Emergency/ adverse weather considerations had been made - grit was available outside in a purpose bin, emergency grab bag was available in the lobby. The care home had functioning air conditioning which meant the environment temperature could be controlled for comfort, and also promote safety in areas such as the kitchen and laundry rooms.

We saw evidence that specific checks were completed in the environment and records were maintained. For example, daily food temperature recording took place in the kitchen. Fridges and freezers were checked to ensure food was appropriately labelled, dated and stored safely. The domestic team had specific check sheets for room cleaning, checking of the laundry room and specific maintenance of machines. We saw that business continuity planning had been completed and weekly housekeeping rotas were seen. We viewed the CCTV and data protection policy and had no concerns.

People told us there were enough staff to meet their needs. They told us, ‘The staff are good, we get checked on regularly and the bell gets answered quickly’. Another person told us, ‘I get checked often and can ask for anything I need’. One relative told us the staff team had grown and, 'Staffing seems about right, seems a lot here'. Another relative said that it can appear 'a bit chaotic' occasionally and felt some staff would benefit from more experience and training of working with people with dementia. One relative had a perception that there weren’t sufficient staff as they often saw them rushing around, but they did confirm there was no impact on care. Relatives told us that they felt the staff had the right skills and experience saying, 'I think the care here is exceptional'.

Staff told us there is a dynamic staffing strategy and there is a need to continually consider skills of staff and staffing ratios as more residents with different needs move into the home. Staff told us some people required assistance from 2 staff, however, the majority needed 1 staff member. Staff said they felt staffing was sufficient, but did also say the numbers would need to be reviewed when occupancy increased further in the future. Leaders told us when agency staff are required, they try to book in advance to ensure continuity of support for people. Staff told us if they needed extra support, management would come and help them. For example, 1 staff member said, 'Managers are also always willing to help, and offer assistance, and ask if we are okay.' Staff told us they had completed the training required for them to be confident and knowledgeable in their roles. This included nationally recognised courses and the care certificate. Staff told us they had received the training required to meet the needs of the people who lived at Wendreth Court.

Staff were visible within the service and appeared to be deployed effectively throughout day 1 site visit during all activities. The reception was suitably covered, we observed the administrator welcoming all visitors, such as family members and visiting professionals, they answered questions and helped visitors to the service as needed. Telephones were answered in a timely way. The registered manager was also visible throughout the service and available to visitors to the care home as needed. Call bells did not ring for prolonged periods of time, and no long periods elapsed between support requests and provisions for people. Staff were available to assist visiting healthcare professionals. Adequate staff appeared available to assist people with their needs in an appropriate and meaningful way. Staff were knowledgeable and trained to provide support to the people who lived at the care home. Staff knew people well, and even where they had been employed for a relatively short time, they appeared comfortable and knowledgeable of their specific role and duties. However, during our second site visit we observed some instances where staff appeared unsure of their roles and the staff team was disorganised. For example during lunchtime not all staff were aware of the mealtime requirements and process.

Staff recruitment files were stored electronically, accessible to certain staff. The administrator demonstrated effective HR support was available for the location. Employee electronic records were viewed for 4 staff and all required information was available. Application forms were completed, interview notes were available. Interviews explored prospective staff experience and appropriate questions asked. Employment history was available and explored. DBS checks were completed prior to starting and references gained were verified. Separate employee electronic files were also in place for training certificates and supervisions. We viewed the staffing dependency tracker and rotas and had no concerns. Additional courses are available to ensure staff can meet the individual needs of people and the provider supports staff to complete personal development courses.

People we spoke to had no concerns regarding infection prevention and control (IPC) telling us that staff wore personal protective equipment (PPE), there is a cleaner at all times and the home is clean and tidy.

Staff told us they had all the necessary equipment and cleaning products required to keep the service clean. Night staff told us they were not required to complete specific cleaning duties, other than any which may require immediate attention overnight. Staff told us the domestic team were efficient, and staff had completed appropriate infection control training. For example, 1 staff member said, '[I have] no concerns. [The care home] is clean. The domestics do their work, and the laundry is done by housekeeping too. We have plenty of PPE.' Staff had completed doffing and donning training to ensure the safe use of PPE. The registered manager told us that IPC was discussed during the interview process, induction programme, in meetings, in training and observations were carried out. Audits were completed and the IPC policy was discussed as part of the policy of the month.

During the site visits all areas of the service were visually reviewed. All equipment, furnishings and flooring were found to be clean and safe. Staff were seen to clean equipment after its use, and equipment was stored appropriately and safely. Clinical waste was appropriately managed and stored, and laundry bags were colour coded to ensure washing was appropriately handled and cleaned. Effective signage and PPE stations were available for staff if needing to apply barrier nursing. Stocks of PPE were appropriate, and appropriately stored. COSHH items were stored safely, and data sheets were available. We observed the laundry to be clean, tidy and appropriate. Domestic cleaning trolleys were lockable, clean and had appropriate storage for items required to keep the environment clean. Kitchens were clean and tidy. This included kitchenettes. Food was stored appropriately, and fridges were appropriately organised, and food was labelled. Person specific items, such as wheelchairs, walking frames, beds, tables and commodes were all seen to be visibly clean and in good condition. Colour coded cleaning systems were in place. Rooms were clean, tidy and organised. Hand washing facilities and pictorial hand washing guidance was visible. However, on the second day site visit we observed some areas for improvement with the lunch service. This included no food covers being used when taking food to people's rooms and people being provided with the show plates. The show plates had samples of all of the lunch meal options they could choose from. This was an infection control risk because the meal could have been on the tray for a long period and be unacceptably cool. The plate could have been offered to a number of residents before being chosen.

The provider's IPC policy was up to date and included references to relevant guidance and legislation. IPC quality audits were completed and identified risks and recorded any actions required. Training records showed that all staff had completed IPC training.

People told us they all had their medication on time and 1 person told us, 'No problems with my tablets. I needed to see the GP once and that was arranged quickly’. One relative told us that there was a complicated process of changing their family member's medication over when they moved to the home but the registered manager assured the family they would manage this, which they did.

Staff told us they had effective and safe medicines training and competency assessments completed. Only senior staff administered medicines. Care staff applied topical creams with direction from senior staff, and utilised body maps and care plan instructions. For example, 1 carer told us, 'No, I don't administer medicines. Some people have creams, and these are applied with the senior direction and also the care plan/ body maps. We can always ask if unsure. I wouldn't use them if I wasn't sure.' Another staff member said, 'I don't administer medicines, but I do check some medicines with the senior, but I don't actually physically administer them. It is just a check that needs to be done, and I go with them to the [person].' Senior staff told us, 'I had specific training, which was face to face, this included medicines training and then I had to have a competency assessment to check my knowledge and practice. The training has been really good.' Senior staff were knowledgeable and told us the ordering and delivery process for medicines was appropriate. All staff spoken to felt appropriate medical support was available for the people at the service.

The provider's overarching medication policy and procedure included links to further guidance on managing covert, as required, homely remedies and controlled drugs. Comprehensive monthly medication audits were completed, however, when issues were identified there was not always actions recorded on the audit itself. For example, the audit identified that some staff required specialist training but there was no follow up recorded. Instead, audit findings are included in the Wendreth Court development plan with timescales, person allocated and completion date. We viewed lessons learnt records which evidenced actions taken following audit findings in relation to how medication is stored and stated, ‘Splitting the stock between trolley and stock room also means that finding the correct medication in the trolley would be easier.’ The training records we saw showed that medication awareness training was completed by 85% of staff, medication administration and practical training completed by 100%. Medication care plans include people's identified need, risks and outcomes. Care plans included preferences for example 1 person ‘likes to take her medication from a spoon, she likes to take a couple on the spoon at a time and would like to have drinking water nearby to swallow these down.’ Care plans also explained the process if someone declined their medication. Clinical meeting minutes viewed included important updates on medication. In regard to the medication storage room, we saw that temperature readings were completed daily for the room and the fridge. PRN protocols were in place where required and all counts of medicines were correct. We made some suggestions regarding recording of medication and found medication that needed to be returned to the pharmacy, which the provider told us they would address immediately.