Woodrow Retirement 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

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 fit and proper persons employed.

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 service did not always have a proactive and positive culture of safety. Staff did not always identify concerns or anticipate potential risks to people’s safety. For example, one person was cared for in a room detached from the main building, staff had not identified the additional risks this posed. Lessons were not always learnt to continually identify and embed good practice, for example whilst falls were recorded and action taken in response to the individual incident, there was a lack of analysis to identify any actions that could be taken to mitigate future risk.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. One person’s relative said, “I would say they dealt with her transition to the home very well. I can’t sing their praises enough; it makes me quite emotional.”

The provider 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 provider shared concerns quickly and appropriately. There had been no recent safeguarding concerns and people, and their families, told us they felt safe. One person’s relative said, “They are absolutely safe, and I could not wish for them to be in a better place.”

The provider did not always work well with people to understand and manage risks. People’s risks were not always identified or routinely monitored, or where they were being monitored records were poorly completed. For example, we found people’s food and fluid charts contained large gaps which meant they could not be relied upon. Staff were not recording when they supported people to reposition to minimise the risk of pressure damage, instead relying on verbal communication. People had risk assessments in place that were regularly reviewed, and some people’s care plans contained good information about how staff could support them to manage specific risks.

The provider did not detect and control potential risks in the care environment. The provider did not make sure that equipment and facilities supported the delivery of safe care. For example, not all radiators had covers which meant people were at risk of burns. Water temperatures were not checked to ensure water was delivered at a safe temperature to minimise the risk of scalds and to mitigate against the risk of legionella disease. Not all windows above ground level were appropriately restricted, which put people at risk of falls from height. The provider told us they would take immediate action to rectify these concerns.

The provider did not always make sure staff were appropriately qualified, skilled and experienced. Staff were not always recruited safely. Following our last inspection, the provider sent us an action plan detailing how they would ensure staff were recruited safely. At this inspection we found not enough improvement had been made. Recruitment files did not always contain the required information. Some mandatory staff training was out of date, and there was no record of staff completing dementia training. One staff member said, “I wouldn’t say [training] is as frequent as it should be.” Staff hadn’t received any formal supervision, although most staff we spoke to told us the manager and deputy manager were always available for informal support, and they felt well supported in their role. Staff told us there were enough staff to meet people’s needs.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. We saw both communal areas and people’s own bedrooms were clean, tidy and fresh. Sufficient personal protective equipment was available to staff.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Since our last inspection, improvements had been made to medicines administration and storage. People’s administration records contained clear, accurate information and were well completed. People’s care plans contained good information about people’s medicines, including ‘per required need’ medicines. This supported staff to ensure people had the right medicines, at the right times.