Whitehaven Residential Home

The provider was previously in breach of legal regulations in relation to consent, safe care and treatment, safeguarding, safety of the premises and governance. Whilst we found improvements had been made, further work was required, and the provider remained in breach of these regulations.

The provider did not always control potential risks in the care environment, for example, the required works in relation to fire safety were still in the process of being completed.

The provider did not have clear responsibilities, systems of accountability and good governance systems. They did not always ensure records were robust and fully evidenced the care people received.

The provider could not demonstrate they always had a positive culture of safety, due to a lack of records. The provider did not demonstrate how they always managed risk to people well. The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The provider had not obtained written evidence of people’s consent to their care or recorded how they ensured legal requirements were met where people lacked the capacity to consent. Therefore, they could not always evidence the assessments they completed when people had restrictions in place.

The provider was previously in breach of legal regulation in relation to notifications. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.

Through our observations, speaking with relatives, professionals, staff and the provider. We were assured people received the care they required in a person centred manner. We saw a low level of impact of the breaches on the delivery of people’s care and their experience and safety. This was due to the stable staff team who knew people well and understood their care needs and risks.

Although further work was required to achieve compliance with the breaches. We saw the provider was motivated and had made progress. In some areas, such as with the work on fire safety, progress had been inhibited due to factors, outside their control. The provider understood the need to be able to evidence the work both they and staff completed.

It will take further time for them to be able to fully establish and embed all of the systems they need and to delegate responsibilities to staff. To ensure the whole team is clear about the expectations of them within their role and their contribution to achieving the aims and objectives of the service.

We have asked the provider for an action plan in response to the concerns found at this assessment.