Whitstable House

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• 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 people did not always feel safe living at the service. We identified 3 breaches of regulation including safeguarding, staffing and risk management. There were not always processes in place to identify, report, investigate and learn from incidents. Staff did always report incidents, the management team had not investigated incidents and made assumptions. Some incidents had not been identified as safeguarding concerns and had not been reported to the local authority. Action had not been taken to learn and reduce the risk of incidents happening again. We found people’s medicines were poorly managed, people did not receive their medicines as prescribed, and this had impacted on their wellbeing. Staff did not always have the skills to support people safely. People were not always involved in managing risks and people told us, their preferences had not always been respected.

This service scored 41 (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 they did not feel safe living at the service. They were concerned when incidents happened there was not always action taken to learn and reduce the risk of them happening again. People did not always feel involved in deciding the appropriate action to be taken. One person told us, “I got hurt by one of the night staff. They came into my room to check my blood pressure. They put the cuff on and inflated it. I told them it was hurting but they just kept going. They were a bit rough with me. In the morning, I reported it. My arm was black with bruising all the way round and the bruise showed the shape of the cuff. They came and photographed it. They didn’t say anything about it. They don’t come near me now, they just leave my tablets.” Another person told us, “I don’t feel safe because the staff are not well trained in moving and handling. They used the wrong sling for me, and I slipped out. It was too big. I slipped off my wheelchair and they put cushions under my feet and told me to pull myself up, but I couldn’t. I can’t remember how they got me into my chair. After that they got me a medium sling, but I said, “You’re not going to use that!” It had a tear in it.” Another person told us, “I was being hoisted and my feet hit a table top instead of the floor, and this was painful. I didn’t say anything at the time to the carer, but I went to manager to tell them, and they said, “Well these things happen. I didn’t think it was a helpful, but I didn’t want to get the carer into trouble.” A relative told us, “(Relative) has had four falls and on the third one they banged their head. Last week they were taken away in an ambulance with stomach pain, but no one phoned me to say they were in hospital.” Another relative told us told us they were happy with the action taken when their relative fell out of bed.

Staff told us they received information about any changes at the handovers which happened twice a day and in the care plans. However, we found changes had not always been made in the care plans.

The systems in place to monitor and analyse accidents and incidents were not effective. The provider had failed to ensure monitoring systems were effectively established to recognise safeguarding concerns and themes or poor staff practice. The poor analysis of incidents and accidents, placed people at risk of harm, as action had not always been taken to keep people safe and address poor staff practice.

Some people told us they met with staff before they were admitted to the service. One person told us, “Yes, I had a needs assessment before I came here, and they spoke with my daughter.” Some people were admitted to short term beds and relatives told us the assessment had been done by the hospital and they had not had any input. A relative told us, “No, it was done via the hospital they had all the details from them, they did a care plan. They have a hospital passport.”

The management team explained the liaison managers completed initial assessments at the hospital, then completed the initial care plans. Deputy/duty managers were responsible for updating them. The management team had been made aware of care plans not being accurate as staff had used information from the hospital assessment to complete the care plans. However, no action had been taken to address this at the time of the assessment. Following the assessment, we were told by the provider, there was now a strategy in place to rectify the shortfall.

Clinical nurse specialists had raised concerns about the quality of care plans. They identified the information had been taken from the hospital notes or referral, so they were not the most up to date or relevant.

When people were referred or first moved into the service their care plan was completed by the service’s liaison managers. People who were admitted to the short stay unit had care plans which had been developed from the information from other health professionals. Staff were given a set amount of time, 3 hours of protected time to complete a person-centred care plan. However, the care plans were not always person centred or had accurate information recorded.

People told us they did not feel they were protected from potential abuse and harm. One person told us, “I feel safe here but not at night. There are 2 male residents that roam and enter rooms. The staff know who they are, but they don’t supervise them. I can lock my door, but I don’t because I’m worried about the fire risk. The fire alarms go off quite regularly because a couple of residents with dementia set them off, even up to 20 times one night." Another person told us, “I feel safe, but I don’t think some of the ladies do as some of the residents with dementia, 2 males, enter the ladies’ rooms. I don’t think they’re supervised enough.”

Another person told us they wanted to move from the service as they did not feel they were being protected. They had concerns about the staff’s ability to use the hoist and slings correctly when they were going to bed. “My leg fell through the [mobile] hoist on the way into bed. The bar almost hit me in the face when they were attaching the sling. When I fell on the bed, my head cracked on the metal bed-head and it hurt a lot. They rolled me to one side and scraped the sling against my face. I asked for the nurse who came and said you haven’t cut your head. The next day my vision was affected like a broken TV.” When we reviewed documentation, we found staff had not reported the incident and the management only found out about it after the person reported it.

Staff described how they would raise concerns, however, this had not happened. We found staff failed to always follow the provider's safeguarding policy. In this policy it details all staff members responsibility when it comes to protecting service users from the risk of abuse. We found evidence that staff were not always raising incidents or concerns when they had occurred and that records were only completed if the person had raised it themselves. However, staff told us, “I would escalate to the manager, deputy manager, complete an incident report with photos on the mobile device then escalate to the deputy manager who signs it off; I am assured it’s been seen by the managers, otherwise it stays “active” rather than “signed off.” Another told us, “Yes, it’s about raising concerns about the place you work in. I know that you can also whistle blow to CQC if you did not want to go to the managers here.” Staff told us, “I feel confident to raise concerns, for example, if staff member was not treating someone right, and I would go to the duty manager and above if needed. It’s about keeping everyone safe, the residents, the staff and the home.”

After lunch we observed staff remove a person’s walking frame from their reach. This action potentially restricted the person’s mobility and placed them at risk of falls. They had to ask to have it back.

The provider had a safeguarding policy in place, but this had not always been followed by staff. We found staff were not raising incidents or concerns when they had occurred and only completed records when people raised the concerns themselves. The management team had not raised safeguarding concerns with the local authority or reported them to CQC. The management team had failed to act to make sure people were and felt safe living at the service. People’s concerns were often dismissed, and people’s fears were not taken seriously by management. Though staff had received training the management team had failed to ensure they understood their responsibilities in relation to safeguarding. This placed people at continued risk of abuse.

People told us they were not involved in their care plan and how they would like to be supported to remain safe. One person told us, “I have no voice in my care. They wrote the plan. I get 2 choices in my meals, but they aren’t very nice. My preferences are only known by some [carers].” And “I don’t feel safe in the sling and hoist. I don’t think they’re trained to use the equipment. I was using a Sara Stedy but I think I slipped once so I wasn’t allowed to use it again. They took away my independence. They didn’t bring me into a collective meeting to discuss why I wasn’t allowed to use it anymore. I’m desperate to try to walk.” Relatives were more positive about how risks to people were managed. One relative told us, “I think, (relative) doesn’t need a lot of care they can walk and they have a panic button around their neck, and they check on them day and night. They are good at responding when they press the button. I don’t know what is in the care plan, no one had discussed this with us.” Another relative told us, “They are aware when they have a urine infection, they get delirium. When they fell it was because the catheter was playing up, they came immediately and sorted them out they were lovely. However, at the time they fell staff should have changed the catheter knowing it was causing them pain and distress.”

Staff described how they would recognise signs and symptoms when people were unwell such as diabetes. Staff told us they would go tell the nurse if they had any concerns. But staff had not recognised how their actions may place people at risk, such as receiving medicines late causing them to shake more and increase the risk of falls.

During lunch we observed one person brought to the table in a tilt-chair. The person was already wearing a tabard and was being fully supported 1-1 by a staff member. The person was not sat upright for their meal. We observed them attempt to lift their head and shoulders up to be more upright but found it difficult. When they said they did not want any more food, the staff member encouraged them to eat more. However, the person coughed a little and spat the food out. Staff then left the person who remained in the chair tilted at the table wearing the tabard.

Potential risks to people’s health and welfare had not always been assessed or documented placing people at risk. People’s care needs were not always clearly documented and reasons for changes in the way people were supported were unclear due to inconsistent information. Care plans contained conflicting out of date information. Staff had not fully explored individual risks, including assessment and mitigation of risks. For example, one person was living with Parkinson’s disease, but there was no reference to this in the person’s care plan including the increased risk of falls. The person did not have a specific care plan or risk assessment to make sure staff had the necessary guidance, including the need to receive medicines at specific times and how this impacted on the person’s life and safety.

Some people told us they were not confident the call bell system always worked. The call bell system often left people wondering if their call had been heard by staff. One person told us, “It [call bell] doesn’t seem to work outside my bedroom. And you don’t know if it’s working because you can’t hear it when you press it.” A relative told us, “I’ve seen people press their button and get no response, and staff seem annoyed at their use. No-one answers call bells.” And “We’ve had to wait for a staff member to wheel (relative) to their physiotherapy appointment.” However, other people told us their call bells were answered quickly, “Yes, they come quickly when I use my call bell.”

Staff described ways in which their fire training helped to keep people safe. However, they had not been given the opportunity to practice their skills. Staff told us, “We have walkie talkies on each floor. Every Wednesday 2pm we test the alarms. We have not had a mock evacuation here yet. There is a fire panel in reception which will light up the area where the alarm has been raised.” Another told us, “I feel confident about the fire alarm, not done a mock fire drill yet.” Further comments included, “I have had fire safety training recently and I feel confident about what to do in an emergency, who to go to first and how to use the fire equipment.”

During our assessment we heard a person calling out, they had been pressing the call bell, but no staff had come, we asked them to press the bell again. We waited with the person, but no staff answered the bell, and the inspector went to find the staff. When staff did arrive the first action, they did was scan the barcode, so the system registered they had attended. Staff did not maintain a safe environment, we observed the medicines rooms on ground and first floor were unlocked, there was a risk people would have access to disposed medicines and sharps bins. There was one person going into other people's rooms, this person had a history of aggressive behaviour. Staff did not know where the person was and had not checked on them. There was no dementia friendly signage to support people to identify their own or communal rooms which contributed to people going into other people’s rooms.

There were processes in place to check if call bells were being answered quickly. People had complained their call bells did not always work. Staff had raised these concerns and the maintenance team had dealt with these concerns. However, there continued to be issues with the call bells and people continued to complain about their not working or waiting a long time for their bells to be answered.

People told us staffing concerns stopped them from feeling safe at the service. One person told us, “I don’t feel safe here because I can’t guarantee anyone coming quickly if I need them. I don’t think they’d cope well with bad situations.” Another person told us, “I don’t feel safe because the staff are not well trained in moving and handling.” Relatives told us there were concerns about staff and staffing levels. A relative told us the staff were often in the communal areas, like corridors or basement, on their phones. We explained staff use a digital record system that looks like a phone. They told us they knew about the devices, but these devices had a phone make logo on the back. We also witnessed staff on their phones during our assessment. Another relative told us, “Ultimately, yes but there are risks, such as the call bell not functioning. The call bell system is electronic you press the buzzer and the fob lights up and it is picked up by the homes computer system. They state staff try to get there within 5 minutes but sometimes there is no one available to attend them, or staff get there in 5 minutes, but they rush in and scan a barcode in the room and then say they will get someone and often they don’t return. Once when I was there, (relative) pressed the buzzer 50 minutes later I went to see the manager and they said they hadn’t received the call, to them it hadn’t happened, and I know it did as I pressed it myself.” A relative told us, “No, because they have constant staffing issues, my (relative) is fed up with learning new names and a lot are on work visas. They heard a lady had fallen out of bed and (relative) went to look, for the carers and they were playing cards. (Relative) says there isn’t enough staff and the ones that are there are running around, it isn’t fair. I feel it is the lack of quality in their recruitment."

Staff had mixed views on if there were enough staff to meet people’s needs. One staff member told us, “Sometimes we don’t have enough staff. I work both day and night shifts on all the floors, more days and usually on the first floor. I think the management are working on recruitment.” Other staff said they thought there were enough staff.

We spoke to staff who told us they were supporting a person one to one to make sure they remained safe. During our assessment, we observed the person in the communal areas without the staff member being present.

There was limited management oversight of care staff, and registered nurses who managed each floor by the management team. The lack of oversight contributed to many of the issues identified at this assessment and led to poor quality care. Training and competency records confirmed, staff had not always received training and competency had not been checked to make sure staff recruited had the skills required to support people. Staff were recruited safely, and the required checks had been completed. However, there was a reliance on sponsorship staff and staff from other services in the provider group. There were no effective systems in place to monitor and mentor staff practice.

People and relatives told us infection control and cleanliness were not always as good as it could be. One person told us they did not have their bedding changed each day. One relative told us they had the impression the public areas are generally clean, but CQC had arrived on a ‘lucky’ day as it’s not usually as clean. Their relative’s room could be unclean. They had taken a video of an incident where faeces had been trodden into the carpet in their relative’s room. The video showed faeces from the entrance round to the side of their relative’s bed. They reported it and the domestic staff cleaned it, but this had not been done when the incident happened. Another relative told us staff did not wear aprons or gloves when serving food. During our assessment staff wore aprons. However, the relative’s comments were corroborated by one person who told us, “Wearing aprons at lunch today was new, they don’t do that usually, it’s because you’re here.” Other relatives commented, “Oh yes, it is spotless, they clean their room every day, and they change their bedlinen.” And “Yes, they know all the cleaners who come in every day.”

Staff told us they had received infection control training and described how they worked to reduce the risk of infection. Staff understood their role to wear appropriate protective equipment to reduce the risk of infection.

The service was clean and odour free. We observed the communal areas were clean and cleaning staff were available to respond to any requests from people or care staff.

There were processes in place to complete infection control audits, records showed audits had been completed until August 2024. At the time of the assessment in November 2024, no more had been completed. However, the service was clean and odour free.

People and their relatives described concerns about medicines including time sensitive medicines not being given on time. This had placed some people at risk of falls and other people experiencing pain. One person told us, “I’ve got Parkinson’s, and I’m supposed to have my tablets at 9[am] but the timing seems to depend on who’s on. One day I didn’t get my pills. The effect makes me shakier.” Another person told us, “My medications should be regular but sometimes it’s missed. I must have paracetamol regularly so sometimes the night staff do it if the carers are running late.” And “My medication is usually an hour and a half late. It should be at 9[pm] but it’s usually at 10.30 [pm] It means I can’t go to sleep until they’ve been.” Relatives told us, “I found a blue tablet on a worktop next to the sink in (Relative’s) room.” Another relative told us, “Yes, they try to make sure they get them on time, but it frequently doesn’t happen. They say they have been very busy when challenged. (Relative) should have paracetamol every 4 hours. They buzzed for their pain relief, and they hadn’t had it 2 and half hours later, I had to go and give them the tablets.”

When confronted with the shortfalls found at this assessment, the management team told us, the short term unit had specific medicines needs and issues with medicine ordering. However, if they were aware of these issues they had not acted to rectify them.

Medicines were not managed safely, placing people at risk of harm. People had not received their medicines as prescribed. Staff had not given medicines at the times prescribed, medicines had not been given due to being out of stock for long periods, and people being asleep. Records showed on the ground and second floor this was a normal occurrence, for example, in a month, there were 80 medicines not given as people were asleep and 19 medicines where no reason was given and 183 occasions when medicines were not available. People’s health and wellbeing was impacted by not having medicines, as these medicines included anti-depressants and to reduce cholesterol. People had not received time sensitive medicines when required, this had placed people at risk of falls. Staff had not followed guidance when giving some medicines, one medicine had been given in the correct way which could reduce how effective the medicine was. Other people had not received their insulin as prescribed, staff had not followed the guidance from the medical professionals. Medicine records were not accurate including the records of medicines with specific recording and storage requirements. Some people were prescribed medicines when required such as pain relief, there was no guidance for staff about when to give the medicines, how often and what to do if the medicines were not effective. The medicine audits completed had not been effective in identifying the shortfalls found at this assessment.