Background to this inspection
Updated
7 December 2017
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This unannounced inspection took place on 19 and 23 October 2017. The inspection team consisted of two inspectors and an expert-by-experience who attended the first day of the visit and one inspector who returned for the second day. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Before the inspection, we reviewed information we held about the service including statutory notifications. Statutory notifications include information about important events, which the provider is required to send us by law. We reviewed the Provider Information Return (PIR) form sent to us. A PIR is a document that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We used this information to plan the inspection.
During our inspection, we spoke with 10 people using the service and one healthcare professional visiting a person at the service. We spoke with 14 members of the staff team comprising of the registered manager, shift leader, a registered nurse, a maintenance technician, eight healthcare assistants, a receptionist and an activities coordinator. We also spoke with a regional director and director of care who were visiting the service.
We looked at 13 care records and 12 medicines administration record charts. We reviewed 18 staff files relating to recruitment practices, training, supervision meetings, appraisal records and duty rosters. We reviewed management records that included health and safety checks, incident and accident reports, safeguarding concerns, complaints and audits to monitor the quality of the service. We checked feedback the service had received from people using the service and their relatives.
We undertook general observations and formal observations of how staff treated and supported people throughout the service. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
After the inspection, we contacted relatives and received feedback from eight of them about their experiences of the service. We received feedback from four health and social care professionals who were involved in the care of people using the service.
Updated
7 December 2017
This inspection took place on 19 and 23 October 2017 and was unannounced.
At our last inspection of 15 December 2014, we found that people did not have enough opportunities to take part in activities of their choice and we made a recommendation about this. We carried out this inspection on 19 and 23 October 2017 and found that the registered manager and provider had taken sufficient action to address this. However, we found the service was in breach of regulations of the Health and Social Care Act 2008 (Regulated Activities) 2014 relating to providing safe care and treatment, person centred care, staffing and good governance and a registration regulation about notifications.
Woodcote Grove Residential Home provides accommodation, personal and nursing care for up to 32 older people and those living with dementia. At the time of our inspection, 27 people were using the service.
People's accommodation was over several floors and included 32 single occupancy bedrooms all with en-suite toilets and hand basins. People had access to communal areas that included two lounges and a dining room. There was a kitchenette on each floor and a main kitchen that was used by a company contracted to prepare meals for people living at the service. People had access to a hairdressing salon on site and a guest room was available for the use of family and friends.
The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People were at risk of receiving unsafe care and treatment. The provider had not ensured staff had the competency to support people in the event of a fire. Staff were not fully supported in their roles and did not receive a regular appraisal of their performance. The provider did not provide staff with an opportunity to identify learning and development needs to improve their practice. Information and records about people were not securely stored at the service and their storage posed a risk of unauthorised access.
The quality of the service was regularly audited and action plans were put in place to make the necessary improvements. However, the provider and registered manager did not act in a timely manner to address shortfalls identified. Audit reports repeatedly identified some of the shortfalls. The registered manager investigated and resolved complaints. However, people using the service and their relatives continued to raise concerns about some aspects of the service. The registered manager did not always submit notifications as required by law.
People received support from staff who understood how to identify and report potential abuse. Risk assessments of people’s health and well-being enabled the registered manager to provide guidance to staff about how to deliver safe and appropriate care. Staff followed guidance to manage identified risks to people’s health and well-being while they respected their freedom. People were supported safely by a sufficient number of staff who had undergone appropriate recruitment checks.
People received support to take their prescribed medicines. Staff competently administered and managed people’s medicines.
People had their care and support delivered by trained and skilled staff. Staff received regular training and refresher courses, which equipped them with the knowledge and skills to undertake their roles effectively. The registered manager undertook supervisions and reflective sessions with staff to develop their practice.
People were supported by staff who understood and followed the requirements of the Mental Capacity Act (MCA) 2005. Staff obtained people’s consent before providing care and support.
Staff delivered people’s care with kindness and compassion and respected their privacy and dignity. People received sufficient amounts to eat and drink. Staff ensured they met people’s preferences, dietary and nutritional needs and monitored their food and fluid intake when needed.
The registered manager assessed people’s needs and developed support plans in relation to their health, background and preferences. Staff did not maintain up to date records of care plan reviews they carried out.
People enjoyed taking part in a wide range of activities provided at the service. However, some people felt that there were limited activities outside the service. People at the end of their life received support that made them feel comfortable, loved and well cared for. Staff had information about people’s end of life plans and respected their wishes and preferences. People received the support they required to maintain their well-being and to access healthcare services in a timely manner.
People using the service and their relatives welcomed the opportunities provided at the service to give feedback and to discuss changes they wanted. The registered manager and provider acted on feedback to develop the service and investigated and resolved complaints. The provider had taken action to strengthen the leadership and management of the service.
You can see what action we told the provider to take at the back of the full version of the report.