Woodleigh Rest Home Limited

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

This key question has been rated requires improvement. We found care records were not always up to date and personalised. Medicines were not always managed safely and people did not always get medicines as prescribed. We identified a breach of the legal regulations. Recruitment procedures for staff were robust and staff we spoke to said they had received the relevant training.

This service scored 62 (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 who used the service was generally positive.

The provider demonstrated a commitment to learning and improvement. They gave examples of learning from previous events. However, concerns regarding care and medicines records identified at the last inspection had not been resolved. This meant safety events were not always reflected accurately in people's care records.

There were processes in place to support a good learning culture however we found the analysis of reports was not always objective and did not always mitigate the risk of similar events occurring to other people.

Feedback from people who used the service was generally positive. People and relatives did not raise any concerns in surveys about safe systems, pathways and transitions.

The registered manager told us there was a safe admission process in place and staff felt well informed about people's care needs. Staff told us they received information about people's care and support needs through care plans and regular handovers.

Feedback from stakeholders was positive. Whilst they did not give any specific feedback about this quality statement, they told us the service had improved and engagement from the registered manager was good.

The provider had systems and processes in place to support safe admissions and transfers of care.

People and relatives felt safe. People and relatives did not raise any concerns in surveys about safeguarding. 1 person told us, “I always felt very safe.”

Staff received safeguarding training. They understood how to recognise and report poor care and abuse. 1 staff member said, “If I had a concern, I would report it to the senior and then to the registered manager and if I was still concerned nothing had been done, I would report to safeguarding.”

People were protected using appropriate and safe moving and handling techniques. People looked well cared for and well presented.

There were processes in place to keep people safe however improvements needed to be made. The safeguarding policy had not been reviewed and we found 1 person’s care plan was not up to date therefore we could not be assured staff were provided with the right information to keep people safe.

People and relatives told us they felt safe. Where people needed support to mobilise staff supported them well. 1 person said, “I have no concerns even when I have a shower, the staff always have time for me. Since I arrived here, I have not had any pressure sores, the staff check me regularly."

Staff told us they received clear information about the risks people were exposed to. Staff attended handovers which provided key updates about changes and they had access to electronic care records at all times so they were able to check what care and support people required. Although staff said they knew people well, we found care records did not contain up to date information.

During the assessment we observed staff using safe moving and handling techniques. We observed risks to people's care managed well and staff followed safe practices.

Risks were not always managed safely. The processes in place for reducing the risk of potential incidents and occurring were effective. However, we could not be assured this was embedded as issues we found had not always been recorded. This meant we could not be assured people were always kept safe and risk of harm was minimised.

People and relatives said they thought the home was safe and well-maintained. 1 person said, “I always felt very safe. The staff tell me of any potential obstacles and guide me safely around. Things were always kept in the same place in my room, so I knew where they are.” Another person told us any issues were resolved promptly. For example, 1 person told us, “The maintenance man has just been in to tell me he has ordered a new remote today and it will be here in the morning. Can’t ask for a better service than that.”

Staff told us the environment was managed safely. The provider told us they were committed to the ongoing maintenance and refurbishment of the home to further improve quality and safety.

We observed the environment to be a safe living space for people. Equipment was in place for people who needed it and was well maintained.

The environment was safely managed. Essential buildings certificates were in place and up to date. There were regular checks of the building and audits produced an action plan which was regularly reviewed. Systems were in place to respond to any maintenance issues and there was a maintenance worker on site who dealt with issues. Regular fire tests and evacuations were in place and the fire system was checked in line with this when we were on site. The records for fire evacuations could be improved. The registered manager told us they would ensure this was carried out and sent us evidence after we had been on site.

People and relatives told us they felt there was enough staff to meet their needs. 1 relative said, “It’s good to know that there were staff around to keep an eye on her.”

Staff told us there were enough staff on duty to support people who were currently living at the home. They described good teamwork to ensure people’s needs were met. 1 staff member said, “There are enough staff at the moment and I'm confident it will be increased if we get more people.”

During observations, we found there were not enough staff to support people safely. We discussed this with the provider and they took immediate action.

Processes for monitoring staffing levels were not robust. The provider used a dependency tool to calculate staffing levels however systems in place had not always identified safe staffing levels. Staff were recruited safely. Appropriate checks were completed on new applicants to ensure they were suitable for the role. Staff received an induction and regular supervision.

People's experiences were generally positive. People and relatives did not raise any concerns in surveys about infection, prevention and control measures.

The registered manager told us they had good links with their local Infection, Prevention and Control Team; they actively sought advice when required and followed up on recommendations. They told us they valued their input and expertise.

We observed most staff following the correct infection prevention and control procedures however, not all staff were bare below the elbow. There were safe outbreak measures in place, but this was not always followed.

The provider had an up-to-date Infection, Prevention and Control Policy Cleaning schedules were in place across the home and were well completed. We saw evidence of good communication with external professionals and evidence advice was sought and acted upon when required. This included seeking support and guidance after a recent outbreak. Feedback from the local infection prevention and control team was positive about communication and the provider's response. The registered manager carried out regular audits including walk rounds and staff observations. There was a good supply of personal protective equipment available to staff.

People and relatives told us their medicines were administered safely. 1 person said, "It is always on time and right” however, records showed people did not always receive their medicines on time.

Staff received training in safe administration of medicines and had their competencies assessed. Staff told us they had time to manage medicines processes such as ordering and receiving medicines.

Medicines were not always managed safely. Peoples medicine care plans did not always reflect their care needs. Information to support staff to safely give ‘when required’ medicines was not always in place. We found examples of people not receiving their medicines. Medicine care plans lacked personalisation. This meant there was a risk people might not have got their medicines when they needed them. We also found some ‘when required' medicines were given inappropriately. For example, where people were prescribed medication to support them with anxiety the required protocols and monitoring were not in place. We referred these concerns to the local safeguarding authority. We also discussed this with the provider and we were assured they were taking action. This was a breach of regulation 12 Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.