Westcliff Lodge Limited

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulations in relation to safe care and treatment.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Incident reports were poorly completed and lacked detail. Managers had not always analysed reports to determine if there were any underlying trends or themes. Preventative and follow up actions were not always recorded to evidence how further risks to people’s safety were being mitigated.

The service worked with healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. We received positive feedback from health professionals about how the service shared information and supported people moving between different care settings.

The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately. Safeguarding reports were not sufficiently detailed. This meant it was not always clear whether safeguarding notifications were being raised with the appropriate authorities when required.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. At our last inspection we found risks to people’s safety had not always been reviewed to ensure they accurately reflected people’s current needs. At this assessment we found continued concerns with the management of risks to people’s health. People did not always have risk assessments in relation to their health conditions. This meant staff did not have guidance in place about how to support them to manage their health needs safely. Where people’s daily care notes evidenced a low intake of fluids, risks relating to dehydration were not well managed. Dehydration risk assessment tools were completed incorrectly, and no actions had been recorded to demonstrate how this risk was being monitored and mitigated.

The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. People’s shared bathrooms were in a poor state of repair. We found broken bathroom tiles on the floor of the downstairs shower cubicle. The shards of broken tiles were accessible to people living in the service and posed a risk to their safety. We found rodent bait boxes in a cupboard which was not securely locked. This meant there was a risk people could access the bait. Health and safety checks had failed to identify and address these environmental risks.

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs. Recruitment processes were not robust and were not being completed in line with the provider’s own recruitment policy. Managers had not always sought evidence of applicant’s previous care experience or verified their conduct in previous care roles. Not all staff had up to date training. Staffing levels did not adequately provide people with the opportunity for social activities and meaningful engagement.

The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading. We found communal bathrooms with stained flooring and evidence of black mould growing on the wall and windowsill. Personal protective equipment [PPE] was not stored safely. Not all staff had up to date infection prevention and control training. Infection prevention and control audits had failed to identify and address these concerns.

The service did not always make sure that medicines and treatments were safe and met people's needs. At our last inspection we found medicines were not always managed safely and records were not always completed accurately. At this assessment we found continued concerns with the management of people’s medicines. On arrival at the service, we found the medicines cupboard and fridge unlocked with no staff present. Stock checks had not always been competed or recorded correctly for people’s controlled drug medicines. We found an out of date topical medicine being administered despite instructions to discard in April 2024. The manager’s weekly medicines checks had failed to identify these concerns.