Wombwell Hall

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 that the service Requires Improvement in relation to the Safe domain. We identified two breaches of the legal regulation in relation to safe care and treatment and staffing. People were not protected from potential harm due to a lack of risk assessments and guidance around people’s care. People did not always have their needs met in a timely manner and felt staff were not always able to support their well-being as they were busy meeting other people’s needs. People’s medicines were not always managed safely. People were not always supported safely across their care pathway. Lessons were learnt though these were not always consistently applied. The home environment was clean however there were some issues in relation to infection control. Safety checks on equipment had not been completed in line with frequency indicated by best practice guidance.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Feedback from people was mixed about whether the service had a learning culture. Some people and relatives commented they had not been asked about their care or whether they were happy which meant the service could not learn how to improve people’s care. However, other people felt if they raised concerns these would be listened to, and improvements would be made. One person gave an example of changes to their care based on their feedback. While some people knew who the overall manager was, many claimed not to know the registered manager. Unit managers were the ‘go to’ people with concerns.

Staff told us they completed reflective practice as a way of learning when things had gone wrong. Staff described how they managed incidents and accidents and told us, “After an incident we always meet to assess why it happened and what we can do to make sure it doesn’t happen again. We remove the hazards. Sometimes it affects the resident's confidence, but we keep encouraging them.”

There were processes in place to support a learning culture however, this was not consistently or effectively applied across all areas of the service. Incidents or accidents involving people had been recorded by staff on the online system and detailed any remedial actions taken for example, where people had fallen and sustained skin tears these were cleaned and dressed. Learning from individual accidents and incidents had been identified and addressed for example, through re-training and meeting discussions. However, risks in other areas had not satisfactorily been managed such as people’s risks being managed, or complaints being learnt from.

People told us their health needs were met. One person told us they were supported to go to hospital to meet with their consultant about their health. A relative said, “What I like here is that they cope with different levels of need, meaning that if [loved one’s] health declines further, [they] will be supported appropriately.” However, we saw recent feedback from a relative that their loved one had been discharged home but had been unwell and was admitted to hospital. We spoke to the Registered Manager about this who agreed at the time of discharge observations to confirm good health had not been completed. Following this, changes had been implemented for example observations needed to be completed before anyone was discharged from the service.

Staff told us people’s needs were fully assessed and they supported people to have the right care so that their needs could be fully met. Staff told us they sought medical advice from GP’s and emergency services as necessary and followed referral processes for example, to the community specialist nursing team, dietician or chiropodist.

Feedback from health and social care professionals who worked with the staff at Wombwell Hall was mixed about whether the service supported safe pathways and transitions. There was mixed feedback about the consistency of effective communication. Some feedback was that there had been failure at times to create appropriate links with other professionals which had resulted in people needing to be re-admitted to hospital. However, other professionals were positive and fed back that, ‘They have received good responses from Wombwell Hall when looking for placement…and to complete an assessment.’

There were processes in place to assess people’s need before they moved into the service and when they were discharged back to people’s own homes or transitioned their care to other services. These processes had not always been followed safely for example some people had not had body maps completed on admission and it was unclear whether pressure damage had occurred prior to or during their time living at Wombwell Hall. When needs had been identified the management team worked in partnership with other professionals to ensure people’s need were met.

People felt safe living at Wombwell Hall. One person said, “I feel safe because I know the carers will do their best to look after me.” Relatives agreed they felt their loved ones were safe.

Staff knew the potential signs of abuse and had received safeguarding training. Staff were able to describe the process to escalate any potential safeguarding concerns and were confident they would be listened to. One staff member said, “The unit managers always take issues forward. They observe the residents and do their report.”

We saw staff attended to people promptly during our on-site assessment. Staff supported people in a caring and kind manner.

There was a safeguarding policy in place which underpinned the safeguarding procedure. The management raised safeguarding concerns with the local authority safeguarding team, responded to requests for information and took actions to reduce future risk. Safeguarding concerns were tracked as part of the service governance however, actions were not always recorded. Safeguarding was regularly discussed with staff for example during meetings to support their understanding. The service had made applications to the local authority to deprive some people of their liberty (DoLS). This is a necessary legal procedure to follow when a person who lacks capacity to consent to their care and treatment, requires restrictions in order to keep them safe from harm. Some DoLs authorisations had been granted however we could not be assured the conditions were followed. For example, one person had medication which required review and although initial contact was made with the GP for this review it had not happened in a timely manner as per the condition and there was no evidence to suggest this had been followed up by staff. Prior to some applications, the appropriate initial capacity assessments had not always been completed in line with legislation to ensure people’s rights were protected and promoted.

People generally felt staff knew them well, knew their needs and supported them safely. However, some people felt their needs had not always been supported effectively to mitigate risks. One person said, “I need turning every two hours to avoid bed sores. They put me on my side, but I slip back, and they don’t check that this is happening.”

Staff told us they involved people in managing their own risks. Staff gave an example of how they encouraged a person who prefers to be in bed to spend time up to reduce the risk of pressure sores. They advised they help manage the risk by ensuring equipment is in place to reduce the risk of pressure damage to the person’s skin.

We observed staff supporting people in line with their needs during our visit to the home.

People were not always protected from the risk of potential harm and unsafe care. People’s care records we reviewed did not contain risk assessments for all of the relevant areas of their care. For example, people did not have risk assessments in relation to their epilepsy or diabetes. This left people at risk of harm as there was not bespoke step by step guidance for staff to follow to mitigate people’s risks and maximise their safety and best possible experience. There wasn’t enough information to support newer staff, who might not know the people well, to manage their needs and risks safely enough. Some people’s care records contained contradictory information. For example, some people’s records contained contradictory information such as, one person’s initial assessment recorded they required support with eating and drinking however, this person received no food or fluids via their mouth and was fed intravenously via a percutaneous endoscopic gastrostomy (PEG) which is a tube that allows you to receive nutrition through your stomach. If the person was supported to eat as the initial assessment had stated, the person could have been at risk of harm. Moving and handling risk assessments for some people were also contradictory about the level of support required or lacked important details about equipment that was needed to safely support transfers.

People did not provide specific feedback about the safety of the environment or comment on the safety of equipment used. People told us they felt safe at Wombwell Hall. For example, one person said, “I feel safe and comfortable as there is a nice atmosphere and staff know what they are doing.”

Staff told us they maintained a safe environment. One staff member said, “We keep the environment safe. [We complete] equipment checks and we also check for hazards.”

The home environment appeared safe. We observed staff using various equipment during our visit to support people to move safely. People used adaptive equipment to maintain their independence for example, while eating. We did find that a COSHH cupboard was unlocked during our visit to the service, but we told staff who quickly addressed this.

We could not be assured that processes to assess the home environment and maintain people’s environmental safety had always been completed. The safety checks shared with us of moving and handling equipment were last completed in January 2023. The provider told us these had been completed in 2024 however we were not provided with any evidence of this. Best practice guidance says this should be completed six monthly to annually. The provider had completed their own internal audits of the safety of the environment. Where some issues had been found these had not always been actioned for example, actions from the last few environmental audits were still outstanding. However, some other inspections by external professionals had been completed to assess and mitigate environmental risks and did not require further action such as for gas, electrical and fire safety.

People gave mixed feedback about the staffing within the service. Some people told us staff were not able to come quickly enough when they used their call bells, particularly at night and for some people this had impacted on them. One person told us, “Need help to get to my commode. This means having to wait 10 minutes, which is not uncommon, then I’m in trouble. I have soiled myself many times.” Some relatives also commented they felt people’s continence needs were not always met and one relative told us, “[loved one] has been wet a couple of times.” Some people also commented that staff did not have enough time to spend with them. For example, a person said, “The carers occasionally have a chat with you, but we’d all like it if they had more time.” This sentiment was shared by other people we spoke with during the assessment. People and relatives liked the staff and felt they had the skills and knowledge required to meet their needs. One relative commented, “The carers seem well trained and are confident in what they do.”

Feedback from the staff at Wombwell Hall was mixed about the staffing levels and deployment. Staff told us there were mostly enough staff to care for people, they only had difficulties when a staff member called in sick at the last minute. Staff comments included, “We muddle through as a team” and, “we can position ourselves so we can see what’s happening everywhere”. We received mixed feedback from staff that there was not always a registered nurse covering each unit in the care home and that this sometimes negatively impacted tasks nurses were responsible for.

During our visit to the service, we saw that staff were busy, though not always rushed, at times some staff appeared task orientated to meet people’s needs.

Recruitment was safe. The provider conducted pre-employment checks which included Disclosure and Barring Service (DBS) checks, references, Right to Work in the UK, and explored gaps in employment history before new staff started working with vulnerable people. These checks reduce the risk of unsafe people being employed. We looked at records in relation to staffing levels and deployment. These records showed that staffing levels were not always in line with the home’s dependency calculations and staffing ladder. At times although there were enough staff, the skill mix was not deployed as per the staffing ladder and dependency calculation. The majority of staff training was up to date. There was a system in place to monitor and manage staff training. There was evidence that action was taken to address any staff who had not completed adequate training and mitigate the risk to people living in the service.

People were generally happy with the overall cleanliness of service. One person said, “My room is cleaned every day and I’m happy with the result.” Relatives told us staff used personal protective equipment (PPE) when meeting their loved ones needs. One relative told us there was an odour “in the whole corridor. It was the same the last time we came.”

Staff told us they had completed training about infection prevention and control. They told us they used PPE where necessary.

We observed the service generally appeared clean, however there was an odour on one particular unit. We saw a water dispensing machine in a lounge was dirty and contained no clean cups for people to access. We also observed limescale on some of the taps and some damage to some of the surfaces in the service. There was a planned programme of works in place to improve the home environment.

Cleanliness and infection control were maintained through scheduled cleaning rotas. The management also completed an infection prevention and control cleaning audit to identify any areas for improvement. Recent audits had found limescale around some taps and this appeared to still be an issue at the time of our visit.

People mostly received their medicines as prescribed including time sensitive medicines. However, people’s care plans did not always contain the most up to date information about people’s medicines and health conditions. When required (PRN) medicines protocols did not include person centred information to help staff support people who were feeling distressed or agitated. People who self-administered their medicines were not assessed. People’s medicines were not regularly reviewed by a GP in line with legal requirements. People with long term health conditions such as diabetes were not always managed safely. People’s preferences about how they took their medicines had been recorded in their care plans.

Staff had received medicines training including specialist training for managing PEGs [percutaneous endoscopic gastrostomy]. Staff worked with the local hospice to ensure people received support with care at the end of their life. The GP did not always respond to requests to review people’s medicines. Although nursing assistants were trained to administer medicines safely, registered nurses managing the units did not always have time to oversee the process.

Staff did not always follow processes to administer medicines safely. Staff were not able to use the electronic medicines administration system (eMAR) effectively. For example, to check for missed doses or access records for blood glucose monitoring. This meant staff were not able to review records or provide this information to healthcare professionals. Staff did not always escalate medicines issues and ensure action was taken. People’s risks had not always been assessed or recorded. Fire risk assessments for people using paraffin-based emollients and risk assessments for bleeding and bruising for people taking blood thinners were not completed. However, staff were aware of the action they should take due to a recent provider update.   Staff did not record the date when medicines were opened. There was a risk people could be administered medicines that had expired. Peoples eMAR charts did not always match their prescribed medicines and stock counts were not always accurate. Medicines audits were not completed consistently across the service and had not identified the issues we found during the inspection. Medicines were stored safely.