Woodleigh Rest Home Limited

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This key question has been rated good. There was an effective pre-assessment process in place and care plans involved people and their relatives. Staff worked together and felt part of a team. External professionals reported having a positive working relationship with the service. The provider needed to improve how they monitor outcomes for people. Peoples care plans lacked information for staff meaning we could not be assured staff were able to always maintain independence and promote wellbeing.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Overall feedback from people was positive. Relatives reported they were involved in care planning.

The registered manager told us the pre-assessment process was effective and ensured the service could meet people's needs prior to admission. The pre-admission process included an initial home visit and communication with people and their families to develop care plans. Staff told us they got up to date information when a new person was admitted to the home.

Reviews of care plans lack personalisation and there was important information missing. Risk assessments were not always in place and some lacked guidance for staff on how to manage behaviours. There was limited information for staff to follow the least restrictive techniques before using medicines.

People and relatives gave good feedback about the care and support they received. We observed no significant weight loss in people. Where needed, people’s fluid was monitored and reviewed regularly.

The registered manager told us people's needs and preferences were fully discussed to formulate care plans. The registered manager liaised with other professionals including GP's, pharmacists, and occupational therapists to ensure clear information was available to staff in order to be able to provide safe care and treatment. They told us how they listened to people's wishes and incorporated this into people's care plans. For example, the service had recently supported a couple who wished to share a bedroom during a recent respite stay.

There was effective systems and processes in place to monitor the weight, food and fluid intake of people and take action where required. Referrals have been made where needed and immediate action taken to change the consistency of someone's food in response to recent decline in swallowing abilities.

People and relatives said they thought the provider worked well with other agencies to provide good support and care. People and relatives told us teamwork was good and staff and the registered manager were approachable.

Staff told us they felt supported by health and social care professionals who were involved at the service. The registered manager made referrals to other agencies when this was required. They described a good working relationship with the GP who visited the home for a weekly 'ward round.' They had recently introduced meetings with the district nurses to improve the lines of regular communication. Staff described effective teamwork and said they worked well together as a team. 1 staff member said, "Teamwork works well. We are doing well."

As part of the assessment, we received feedback from external health and social care professionals. Feedback was positive, they said the registered manager worked collaboratively and demonstrated good communication. They told us, "I think there has been a vast improvement." Feedback was the registered manager was approachable and welcomed advice.

The provider had clear and effective systems and processes in place which demonstrated effective partnership working within the service's staff team, as well as with external professionals and partners. There was evidence in care records of professional visits and notes from district nurses and GPs. As well as reviewing a range of records showing good partnership working with other agencies to provide good care from dentists, opticians, diabetic clinics, specialists in hospitals, continence service and social workers. Where people had conditions on their Deprivation of liberty safeguarding there was evidence to show this had been complied with and demonstrated effective partnership working with professionals to meet these requirements.

People and relatives told us they were supported to live healthier lives. 1 relative told us liaison with the GP was good. They told us they were involved in discussions with the GP and their relatives' medication had been changed which led to a positive outcome. Another relative said staff were proactive about referring to health care professionals. They said, "They [the staff] never hesitate to seek the GP’s advice. They always let me know when they do this."

Staff told us they supported people to live healthy lives. The activity coordinator spoke positively about the impact the activities programme had on people and their lives. They said after sessions people appeared "more vibrant and settled." They said the development of more activities had been positive for individuals and the atmosphere at the home generally. Staff told us how they promoted gentle exercise and actively encouraged people to maintain their independence and mobility. 1 staff member told us they promoted healthy eating whilst taking into consideration people's individual choices and wishes.

Care plans demonstrated how the provider promoted healthier lives for people with the involvement of other healthcare professionals. However, evidence of people’s involvement in care plans was not always clearly recorded.

People and relatives said they felt well supported and most people said they were involved in reviewing their care plans.

Staff told us the safety and quality of the care people received had improved. They told us when any issues were identified action was taken which led to improved outcomes for people. 1 staff member gave an example about how they had discussed some changes with a person and their relative in relation to their personal care needs and this was implemented immediately.

The provider had systems in place to monitor the outcomes for people, and records showed clinical checks were completed for elimination requirements. We saw evidence of good partnership working with other professionals, improving the quality of the care for people, and clear reviews done by professionals showing ongoing monitoring of clinical needs. We did, however, see a shortfall in the monitoring of outcomes relating to people's mental health and wellbeing needs. Behaviour support plans were not robust and lacked guidance to staff on how to maintain a healthy relationship between medication and managing behaviours.

People and relatives said they were routinely offered choice and control. 1 person said, "We chat about things we would like to do and I think the staff listen. I never feel I have to do something if I don’t want to.”

Staff understood the importance of asking for consent. 1 staff member said, "I use continuous communication with the resident to make sure I am taking consent before offering care and support. For example, before going to give anyone personal care, I always communicate with them and try to know how they are feeling."

Care plans contained evidence of consent from people or their representatives where appropriate. However, this was only evident at the start of the implementation of the care plan, we saw no evidence of involvement of people or relatives in reviews of care.