Wood Hill Grange

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 assessment we rated this key question requires improvement. At this assessment 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 regulation in relation to people’s safe care and treatment and the ways people’s medicines were managed.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff 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. We identified improvements were required. New processes seen at our last inspection in March 2024 had not been sustained or embedded into practice. We discussed with the provider how identification of lessons learned and clear communication of learning to the staff team could be strengthened. They were aware of this, and a new management team was being established to ensure improvements were made.

Staff were aware of the procedures for reporting and recording accidents and incidents. They explained the falls protocol and the steps to follow when someone experiences a fall. However, evidence of reviews and analysis were not always recorded in people’s plans of care and there was no formal sharing of learning among the team. The new manager assured us this was commencing.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care. We saw evidence in care plans of visits and referrals when required. People and relatives told us health care professionals regularly visited the service. Relatives confirmed their family member saw their GP and could request a visit if they felt they were unwell. However, we observed health care advice was not always followed. For example, one person was assessed as at risk of choking and the advice was to use an open cup for drinks. We saw on 2 occasions that staff were giving drinks using a spouted cup, putting this person at potential risk of choking.

The new management team worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The manager shared concerns quickly and appropriately and was working with the local authority providing requested evidence to progress investigations. People told us they felt safe. One person said, “Yes, I feel safe.”

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The care plans did not reflect people’s current needs or risks. For example, one person was assessed as at risk of falls. We looked at their falls risk assessments, general risk assessment and mobility care plan, each one stated a different level of risk, therefore it was not clear which was accurate, and it did not give clear guidance for staff to follow to manage the risk.

Care plans were currently being updated and reviewed as the local authority had identified this required improvement to ensure people’s needs were met safely. However, care plans that had been updated still had contradicting information and they lacked appropriate detail to enable staff to meet people’s needs. People told us staff did not always understand their needs and did not support them appropriately. One person said, “Staff did not move me correctly, they caused me a lot of pain, when I tell them they say sorry, but they [staff] do not learn.”

The service did not always detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care. Maintenance was carried out and regular checks of equipment were in place. However, although the manager told us new equipment had been ordered, equipment that was not in a good condition was still being used. For example, pressure relieving mattresses we saw were badly stained with ingress of urine. We also identified technology did not fully support the delivery of care, there were insufficient laptops to access care information to ensure staff had access to full care plans to be able to understand people’s needs and any changes to deliver safe care.

The provider did not always make sure there were enough qualified, skilled and experienced staff effectively deployed. 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.

A dependency tool was used, and staffing was delivered in line with this. However, we found staff were ineffectively deployed, they were task orientated and not delivering care in a person-centred way. Staff received lack of guidance, support and mentoring. People said the staff were not always available. One person said, “There are barely any staff around, they never stop to have a chat they come in the door and then they take off again.” The new management team was aware of the staff culture and the need to make improvements. They were working with the team to improve the support and supervision. They had arranged regular meeting and group supervision. Staff we spoke with felt more assured with the new management team and felt more supported.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. We found predominantly the service was maintained in a clean condition. One person said, “The cleaners are good they clean my room.” However, we found areas where a deep clean was required. For example, the dining and lounge chairs had ingress of urine and a build-up of engrained food debris. We also identified a number of mattresses that had ingress of urine and were not able to be cleaned.

The housekeeping team explained they had less hours available to be able to carry out deep cleans and said, “On many days we are short staffed and are unable to do the cleaning we would want to.” The manager explained they had one post to fill and were looking at recruiting. They also told us they were looking at the housekeeping rota to ensure a consistant allocation of staff over all seven days each week.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. Records showed that medicines were given at correct times and appropriate intervals were left between doses. Medicines were stored safely and securely throughout the service. Effective processes were in place for the management of controlled drugs. For people with diabetes, blood tests were carried out regularly and recorded accurately. However, records for adding thickening powder to drinks, for people who have difficulty swallowing, were not always completed accurately. Therefore, we could not be assured people were safe from the risk of choking. The site of the application of topical preparations such as creams was not always recorded, so we could not be assured they were always being applied safely. Care plans did not always contain up to date, personalised information about how to support people with their medicines. When people had their medicines covertly, hidden in food or drink, information to support staff to safely give medicines this way was not always available. There was a risk that people were not given their medicines safely. Medicines audits were carried out regularly, however, they were not always effective in identifying medicines-related issues occurring in the service.