Woodfields Residential Home

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

Our rating for this key question remains requires improvement. We identified 1 breaches of the legal regulations. Care plans and risk assessments were not always in place, up to date or reflective of the care people received. People were restricted and Deprivation of Liberty Safeguards (DoLS) were not always updated to reflect people’s needs. Medicines were not always managed in a safe way and areas of the home required improvements. However, there were enough staff available for people, who were safely recruited. Staff were aware of safeguarding procedures, and these were followed when needed.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were unable to tell us how they were involved with the learning culture in the home. One person said, “Not heard of any residents’ meetings, they ask if you are okay, anything they can do.” A relative told us, “I am not aware of any formal reviews since admission.” Which had been 3 years previously.

The registered manager told us how they implemented learning in the home. For example, they told us they had found concerns with the medicines management and had changed the pharmacy provider to rectify these concerns. However, they were unable to tell us how they had implemented a positive learning culture throughout other areas of the home such as how they had used the findings from our last inspection to implement changes.

There was a lack of effective systems in place that identified concerns and drove improvements within the home. There was no evidence of learning in the home, care plans and risk assessments had not always been reviewed to ensure future risks were mitigated so that lessons could be learned.

People and relatives raised no concerns with the systems and transition process. One relative advised that on admission staff had listened to the family who had told staff about the person’s likes and dislikes and that they needed reassurance at night and cups of tea.

The registered manager told us there was a system in place to ensure people’s needs were assessed before moving into the home. This included a face-to-face assessment of the person to ensure their needs could be met. Staff told us they were aware people’s needs were assessed before they started using the service.

As part of this assessment, we asked for feedback from the local authority. They had no up-to-date information to provide to us.

People did not always have care plans and risk assessments in place that identified the support they needed. We found that there were missing care plans and risk assessments for people with health conditions such as constipation, dementia and schizophrenia. It was therefore unclear how the information gathered from the assessments was used. This placed people at risk of unsuitable care.

People and relatives raised no concerns about safety. One person told us, “I feel very safe here it’s the people who work here very very good, if got a problem here for you, can speak to any of the staff.”

The registered manager and staff told us there were procedures in place to ensure safeguarding concerns were considered. They had received training and were aware of what safeguarding was. One staff member told us, “It is making sure we look after the vulnerable people and raising any concerns we may have.”

We did not observe anything of concern during our site visit.

When needed Deprivation of Liberty Safeguards (DoLS) were not always in place, for people, they were not always reflective of all restrictions that had been placed upon people, such as bed sensors and rails. As care was not always reviewed then we could not be assured these DoLS were fully reviewed and were up to date. We found some people had restrictions placed upon them which they had not consented to. For example, we were told one person had a restriction placed upon them, although the registered manager told us this person lacked the capacity to make this decision there were no capacity, or best interest decisions in place to confirm this. There were safeguarding procedures that were in place and followed when needed.

We received mixed feedback on how people’s risks were considered and managed. A relative shared concerns around when a person had fallen, and bed rails had been introduced. People we spoke with raised no concerns.

The registered manager told us there were, “No real risks to people currently.” They told us people had information available in their care files as needed. When we raised concerns that care plans and risk assessments were not always in place or lacked detail, they could not provide an explanation for this. However, staff knew people well, including their individual risks and the support they needed.

We saw that protective bumpers that were fitted to people’s beds were not always the correct size, this placed people at risk of harm. However, staff had considered other risks to people. For example, we saw staff transferred people with aids they had been assessed to use.

The processes in place to manage risks were not effective. Care plans were not always in place, reviewed or monitored. For example, when people had dementia or health needs, there were no condition specific care plans in place. There were no audits or oversight in place that monitored the care and support people received.

People and relatives raised no concerns about the safety of the environment.

The registered manager told us areas of the home had been identified as in need of repair and this was being worked upon by the provider. This included replacing some furniture and flooring. They confirmed there was no internal audit of these areas or action plan in place which identified these concerns.

The home was tired looking, and we saw areas that needed repainting and repairing, including walls and ceiling. We also found some parts of the home were cold , which we shared with the registered manager. We saw some areas were being repaired during our site visit.

There were no effective systems, including an audit or action plan in place that monitored the safety of the environment. Where concerns had been observed by the registered manager these had been actioned for example, replacing some of the chairs. They confirmed there was no internal audit of these areas or action plan in place which identified these concerns

People and relatives were happy with the staff that supported them and felt they had the skills and knowledge to do so safely. One person said, “Always a lot of people around, don’t wait, lovely, all very nice.” A relative commented, “Always staff around whenever we visit, evenings, weekends, we know the staff, familiar faces, if he wasn’t happy would let us know.” Another person told us, “These lot know what they are doing.”

Both the registered manager and staff felt there were enough staff available for people. However, the registered manager confirmed there were no systems or effective tools in place to work out how many staff were needed. Staff told us they had received up to date training and felt this helped them support people.

We saw there were enough staff available for people and they did not have to wait for support. We saw for long periods of time staff remained in a different room to people and there was little interaction for people during this time. We feed this back to the registered manager.

There was no system in place to monitor the recruitment of staff, which meant not all recruitment checks were available to review. We found 2 staff did not have the relevant checks stored on their online recruitment folder, after our site visit, we received confirmation these checks were in place. There was no effective system in place to ensure there were enough staff available for people. However, on the day of our site visit we saw there was enough staff available for people. There was a system in place to ensure staff had received up-to-date training.

We received mixed feedback on IPC. A relative told us, “The room stinks [example]” They also spoke of the bedroom being cold until recently when the radiator was changed and said, “Laundry not very good, whites not white and items go missing.” Other people raised no concerns. One person said, “When assisting they wear aprons and gloves.” They were happy with how their bedroom was kept.

The registered manager told us there were some areas they had identified as of concerns, and these were being addressed by the provider. They told us they had an external Infection Prevention and Control (IPC) audit which they were working through. Staff told us they were aware of and had received IPC training they told us personal protective equipment such as gloves and aprons were available for them to use in the home.

We observed there was a strong smell of urine in one of the rooms. Some of the chairs which may pose a risk of cross infection had been removed from communal areas and placed in the conservatory. We also saw a floor was being replaced.

There was no effective system in place that monitored IPC in the home. There was an external IPC audit that had been completed, and this identified actions. However, the action plan was blank and did not identify the actions the provider was taking or had already taken.

People and relatives were happy with how medicines were administered. One person said, “Senior care assistants or manager give medication, know what I’m taking it for but not names, no problems at all.” A relative told us, “If any changes with medication they tell us.”

The registered manager told us there was a system in place to monitor medicines. However, they could not provide an explanation why the stock level was inaccurate and ‘as required’ protocols were not in place and had not been identified. However, staff told us they had received training to administer medicines, had their competency checked, and felt safe doing so.

The processes in place were not always effective in identifying areas of improvement. An audit was completed on medicines however, this counted the stock dose of medicines and did not consider anything further. When stock checks were inaccurate, this was documented but no further action was taken. This meant we could not be assured people had always received their medicines as prescribed. Furthermore ‘as required’ protocols were not always in place to ensure staff had the guidance available to ensure people received these medicines as prescribed.