Walton Park Care Home

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

People were not always kept safe from avoidable harm due to risks to people not always being appropriately managed and lessons not being learnt from accidents and incidents. Care plans included incorrect information that could lead to people’s rights not being protected. Medication storage was chaotic. Whilst the environment was clean, areas of it were not safe. There were enough staff to meet people’s needs. However, some staff did not receive regular supervisions and their mandatory training was not up to date. We observed people enjoying their dining experience and thoughtful interactions between people and staff.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives felt their concerns were not always listened to or resolved effectively. One person told us, “There is no point in speaking out because no-one takes any notice anyway. They are all fakes.” Another person told us, “I told the [registered manager], that I didn’t like sitting in the dining-room because the light was shining in my eyes and he said I could always move to another table. I wasn’t satisfied with that answer – if you move to another table here it upsets everyone.” A relative added, “I’m not happy that there is no communication with the doctor about my relative’s situation. [The registered manager] has said he will deal with this but we still haven’t heard anything.”

Staff were able to explain how lessons were communicated following incidents. One staff member told us, “If there are any changes the manager will inform us. There is always communication to the team.” Another staff member said, “For example they had a change yesterday and it was sent on our [electronic monitoring] messages - They write a message on there when there is a change of care plan. We need to click that we have read it so they know.”

A recent relative feedback survey reported that 25% of relatives had stated there were not enough activities in the service to keep people engaged. Comments included, “Boredom needs to be addressed, I have heard comments from several [people]” and “not much in the way for activities for dementia residents.” However, we did not observe any meaningful activities taking place during our assessment. One person also told us that they would like to have bed rails to make them feel more secure whilst in bed. We fed this back to the registered manager who informed us they would look into this. We have since received confirmation these have now been installed.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and their relatives gave mixed feedback on whether they felt safe at the service. One relative told us, “I feel dad is safe here. They got the falls team in following a fall. Communication is good.” However, one person said, “I do find some of the staff are bullies – the way they boss you about.”

Staff had good knowledge on safeguarding and were able to explain the steps they would take if they suspected someone was being abused. One staff member told us, “We have done this training online. Anything we notice - even smaller things such as if a staff is rude to someone, I would report it and management will report and investigate it. I don't process the safeguarding, the management do this such as meds issues or any type of abuse, incidents, falls as well. We report anything to the management and they do the report to safeguarding.”

We observed people receiving kind and compassionate care during our onsite assessment.

The registered manager did not always inform the Care Quality Commission (CQC) of reportable incidents. These included unexplained bruises, allegations of abuse, and people being able to leave the service without support from staff. We informed the registered manager of this who has since sent in the required statutory notifications to CQC. Mental capacity and best interest decisions were not in place to ensure people’s rights had not been unlawfully restricted. Mental capacity assessments were not decision specific and were missing for elements of care being delivered such as dental treatment and delivering personal care. The registered manager’s understanding of the Mental Capacity Act 2005 was also limited. Following the onsite assessment, the registered manager sent us examples of updated mental capacity assessments. However, these did not always include who had been involved in making the best interest decision for people, such as family members. This was a breach of Regulation 13 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People’s relatives felt risks to their loved ones were managed well. One relative told us, “[Person’s] dementia is severe so there’s challenges here. He has additional nutritional needs so has grazing boards and [nutritional drinks] to keep his weight up. Recently I chatted with [the registered manager] about [person’s] nutritional needs and one of the things we spoke about was if [person] was asleep during the day and missing meals, what could be done at night. So extra food is now available for him at night.”

Staff were aware that risks to people were not always managed appropriately. One staff member told us, “I do find that staff don't always record [repositioning and bowel movements] so I will write if it wasn't documented to highlight.”

We observed people enjoying a pleasant dining experience as they were being supported appropriately according to their needs and in a caring manner. Those on pureed diets had meals that were prepared to look appetising.

Risks to people were not always appropriately managed. One person required constant one to one care to keep them safe. However, we identified an occasion when the member of staff providing the one to one care left the person unaccompanied which resulted in the person falling. On another occasion a person’s wardrobe fell away from the wall and broke whilst the person was in the room. There were multiple varying accounts of how this had occurred with no certainty. Despite this, people’s wardrobes had only been fixed to the wall to prevent reoccurrence two months later. This left people at a prolonged period of risk of harm. Furthermore, people who required regular repositioning to prevent a breakdown in their skin integrity were not always sufficiently supported. For example, one person’s care plan stated they required repositioning every 2-4 hours. However, we identified numerous occasions where this had not occurred. For example, on one occasion the person had not been repositioned for 8 hours, and on another occasion not for 11 hours. This left people at risk of pressure sores developing.

People felt their environment was not always up to standard. For example, one person had continence pads being stored in their room. They told us, “I asked [staff] to remove those boxes over there. They were piled high. They’re pads and they said that they are mine, but they come in and take them for other people. They must think I’m daft. Anyway, they’ve taken a few of the boxes away. I don’t like them being left like that in my room.”

Staff felt they had the equipment they needed to provide safe care. One staff member told us, “As seniors we have everything we need. Whatever we have asked for it has been provided.”

We observed areas of the environment which needed to be improved to provide safe care. A glass panel on the mezzanine balcony had shattered on 2 August 2024. Furniture was put in front of it on the balcony level, and chairs underneath it on the lower floor. The glass panel had still not been replaced at the time of our inspection. We received confirmation from the new manager on 8 December 2024 that it had been fixed.

Appropriate action had been taken during other incidents involving the environment. For example, when a discrepancy in maintenance check dates for slings for hoists was identified, the slings were taken out of use until a maintenance check had been completed. Additional positioning support was provided to people who required it during this time.

People gave mixed responses about staffing at the service. One person told us, “I go out to find someone if I need help with anything. No, they are not always around – they’re just doing their job, and they can’t be everywhere at once. I have trouble sleeping – they do pop their heads around the door to see if I’m OK. They seem to know what they are doing.” Another person said, “I have used the call bell and it didn’t take them long to get here. There is always someone around. I don’t feel lonely – they do come by to see how I’m doing, during the night-time too.” However, other people noted on the manner of some of the older staff. One person said, “There was a really loud noise going on the other night and I was worried about it. I went out to find out what it was. The staff member wasn’t too happy that I’d got out of bed they were a bit grumpy.” Another person said, “Some of the older staff are quite bullish in how they deal with us. The younger ones are nicer.” A further person added, “The younger ones very helpful and pleasant – I expect they’re worried about losing their job. The older ones are not as helpful, shall we say.”

Staff felt there had recently been an improvement in the number of staff at the service which had improved people’s experience. One staff member told us, “They just raised the staff. I raised this concern and there is now extra staff. There was a couple of months when we were short staffed. We always try our best rather than compromise people's care.” Another staff member said, “I do think it’s enough, especially now we have an extra carer in the building. I felt much better when I worked a night last week.” Staff also felt the training they received was sufficient for their roles. One staff member told us, “Training we do on the [online] platform. First aid training is face to face and the rest of it online. I can request additional training if needed.”

We observed those with call bells that were accessible received a quick response from staff when these were used. People were not left waiting for care.

There was currently a high use of agency nurses at the service. Staff supervisions were not occurring on a regular basis. We identified one member of staff had not received a supervision meeting for 12 months. Another staff member had not had a supervision meeting for 17 months. Furthermore, one staff member had not had a supervision meeting at all since they had started their employment at the service in December 2023. This meant performance issues could not adequately be addressed, nor additional support for staff identified and resolved. Staff member’s skills were not always kept up to date. The provider’s training matrix demonstrated several staff members had been required to complete refresher courses in various training modules. However, these had still not been completed for over a year. This meant the provider could not be assured staff’s knowledge and skills in providing care were up to date.

People felt the home was kept tidy and clean. One person told us, “Two ladies do the cleaning. It’s all done well.” Another person said, “This room is cleaned regularly, and aprons and gloves are always worn for personal care.” A further person added, “I’m happy with the cleaning. Yes, they wear masks and gloves if they need to.”

Staff felt they had appropriate personal protective equipment (PPE) to deliver care safely. One staff member told us, “We do have gloves and shoe wraps and aprons for showering. We have different white and red bags for soiled laundry.” Another staff member said, “We have wipes for trolleys and cupboards in medicines room. We have gloves and aprons as well.”

We observed the environment was clean and modern. There were no malodours other than in the entrance of one unit. The garden was well maintained.

Infection control audits were completed monthly. No issues had been identified although this was expected due to the service being newly refurbished.

People felt confident in staff supporting them with their medication. One person told us, “Medication is all done well – I have to have it every day.” Another person told us, “I do have medication on and off all day. They do tell me what I’ve taken – I ask as I like to know.

Staff were not always aware of safe medicine administration procedures. For example, one staff member told us, “We put the creams on [people] and when they are running out, we tell the seniors. We put in care notes but I'm not sure if it needs to be on a [medicines administration record] chart.” Staff also felt their competency to administer medicines was adequately checked by the management team. One staff member said, “We have a competency check from deputy manager every six months.” However, this was inefficient as it had not identified the shortfalls around medicine administration we found during our assessment.

Care plans were not always clear in how medication should be administered. For example, one person’s care plan stated that they were to receive their medication covertly. However, staff said they were unaware of this. The registered manager then told us that this was incorrect and they were to receive their medication openly. This had left the person at risk of receiving their medication covertly without the appropriate legal documentation in place. Poor administration practices were taking place at the service. For example, senior carers were completing the medicine administration record for applying a person’s prescribed cream when this was done by other staff in the service. This meant there was no accurate evidence of who had administered that medicine. The medicine storage room was chaotic and unorganised. There were a large amount of returns stored in large crates which were poorly organised and did not appear to be logged. However, these were collected by the pharmacy during our assessment.