• Care Home
  • Care home

Archived: Woodbury

Overall: Good read more about inspection ratings

8 Kingsdowne Road, Surbiton, Surrey, KT6 6JZ (020) 3740 2316

Provided and run by:
Balance (Support) CIO

All Inspections

13 December 2022

During an inspection looking at part of the service

Woodbury is a residential care home providing personal care to up to 15 people. The service provides support to people with mild to severe learning disabilities or autistic spectrum disorder. At the time of our inspection there were 5 people using the service. The care home accommodates people in one adapted building in Surbiton.

People’s experience of using this service and what we found

The service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

Right Support

The service worked well with other agencies to do so. The service had enough staff, including for one-to-one support for people to take part in activities and visits how and when they wanted.

Right Care

Staff supported people to express their views using their preferred method of communication. People had the opportunity to try new experiences, develop new skills and gain independence.

Right Culture

The registered manager worked hard to instil a culture of care in which staff truly valued and promoted people's individuality, protected their rights and enabled them to develop and flourish. Staff felt respected, supported and valued by senior staff which supported a positive and improvement-driven culture.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 6 June 2019).

Why we inspected

We undertook this inspection as part of a random selection of services rated Good and Outstanding.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has remained good.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Woodbury on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

8 May 2019

During a routine inspection

About the service:

• Woodbury is a residential care home that provides accommodation, respite, care and support for up to 15 people with a learning disability and/or autism. At the time of our inspection 11 people were using the service.

People’s experience of using this service:

• The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

• Premises were adapted to meet the needs of people living there and ensured that they were safe. Some improvements to the cosmetic environment had been identified and the management were working to address these.

• Staff knew how to safeguard people from the potential risk of abuse, and ensured that they followed risk assessments to mitigate potential risks to people.

• The home was responsive to people’s healthcare needs and ensured that people received appropriate support to meet their healthcare and nutritional needs.

• People were supported by attentive and supportive staff that understood their conditions and were sensitive to people’s communication preferences.

• People were supported to access a variety of activities both inside and outside of the home. These were personalised to meet their preferences and supported their independence.

• Staff knew how to treat people with dignity and respect, as well as supporting them with any cultural or religious requirements.

• Management were effective in ensuring the home was well-led and that staff received the right support to carry out their roles. Quality assurance checks were maintained to review the quality of care delivery.

Rating at last inspection:

• At our last inspection of 31 January 2016 the service was rated ‘Good’. (Published 04 March 2016)

Why we inspected:

• This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.

Follow up:

• We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned for future dates.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

28 September 2016

During a routine inspection

This inspection took place on 28 and 30 September 2016 and was unannounced.

Woodbury provides residential care for up to 14 people on a permanent basis and also has one bed available for respite care. It provides care for people who have learning disabilities and/or physical disabilities, including people with autism spectrum disorders, epilepsy and mental health needs. At the time of our inspection 14 people were using the service on a permanent basis and another person visited for respite care on the second day of our inspection.

There was 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.

At our last comprehensive inspection in November 2015 we gave the service a ‘requires improvement’ rating. We followed up our concerns about insufficiently robust risk assessment, risk management and audit systems at a focused inspection in January 2016 and found they had all been addressed. We also found in November 2015 that the provider was breaching the regulation in regards to safe staffing, because there were not enough staff deployed on shifts to keep people safe. We did not follow this up in January 2016 because not enough time had passed for the service to demonstrate improvement in this area.

At this inspection, we found the provider had increased staffing levels and carried out an assessment of people’s needs with regard to staffing levels. We saw there were enough staff to care for people safely.

People told us they enjoyed living at Woodbury. One person said it was “very good.” Another person said, “I like it here. I have friends here.” A third person told us, “I like it. It’s a nice place and I have my own room.” People felt safe using the service, were able to report concerns and staff knew how to recognise and report abuse. Managers followed appropriate procedures to follow up allegations of abuse. Robust procedures were in place to help ensure that unsuitable staff were not recruited to work with people.

There were systems in place to identify and manage risks to people’s safety in proactive ways that did not unnecessarily restrict people’s freedom. This covered both general risks posed by the environment and risks that were specific to individuals. Risk assessments were personalised and regularly updated. Staff had opportunities to discuss safety concerns and the registered manager used systems to collate information about accidents, incidents and concerns so they could identify any trends and monitor risks to people’s safety.

Medicines were stored, handled and administered safely. Although the service had reported a number of medicines errors during the year before our visit, the provider had identified this and put measures in place to prevent errors from happening and to ensure that errors were quickly identified and dealt with appropriately.

Staff received the supervision, support and training they required to perform their roles effectively. This included special training in response to feedback from outside professionals about staff knowledge. The provider enlisted healthcare and other professionals to provide specialist training to ensure staff were up to date with current best practice in supporting people with their specific needs. Healthcare professionals told us staff were good at following professional advice and meeting people’s healthcare needs. Staff supported people to access healthcare and other services when needed and people had personalised plans to help staff provide them with the care and support they needed and wanted for their health.

Staff obtained people’s consent before carrying out care tasks. Care plans contained information to help staff do all that was reasonably possible to help people understand the information they needed to consent to their care. If people did not have the capacity to consent, the provider followed the processes that are legally required by the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS) to ensure that decisions made about people’s care, including any restrictions on their freedom, were made in their best interests and did not compromise their rights.

People received a variety of nutritious food and drinks that they enjoyed. Staff were aware of people’s specific needs around nutrition, including cultural and religious needs and other dietary requirements, and took action to make sure these were met.

People and relatives fed back that staff were kind and caring. We saw staff interacting with people in a way that was respectful and friendly, although sometimes staff did not talk to people when supporting them to eat which meant they may not have been fully aware of what they were eating or what staff were doing. Staff knew people well and used appropriate methods of communication according to people’s needs, although there was a lack of detailed information about people’s life histories that would help staff understand people better. We recommend that the provider explore life history work with people and, if appropriate, families and others who know people well.

Staff offered people choices about their care, gave them the information they needed to make choices and kept them informed about what was happening. Staff showed respect for people’s privacy, dignity and independence, although people’s personal records were not always stored securely. Managers were in the process of taking action to address this concern.

People had assessments of their needs and these were used to complete personalised care plans. The care plans showed the support people needed to complete everyday tasks and activities, how they preferred to be supported and what was important to them. Care plans were designed to enable staff to support people in a person-centred way. Although some relatives and visiting professionals felt there could be more activities provided, the registered manager was in the process of making improvements to the activities timetable and a number of group and individual activities took place during our inspection. People received support to attend activities and religious services in the community, go on holidays and use the garden at home.

There were systems to ensure that the provider responded appropriately and promptly to concerns and complaints that people and visitors raised. We saw examples of these showing action was taken to resolve any problems and prevent them from happening again.

People, staff and relatives felt the registered manager led the service well. The manager had worked to make the culture of the service more supportive, person-centred and open. Staff told us they had opportunities to express their opinions and the manager listened to them. Roles and responsibilities of staff were clear and staff knew whom to approach for help and support. The manager was aware of challenges faced by the service and told us how they addressed these, such as issues with poor record-keeping. We saw improvements had been made in this area. People, staff and relatives felt the service had improved over the last year and was still getting better. The provider used a range of audits and checks to assess, monitor and improve the quality of the service. Where these identified action to be taken, the registered manager ensured this was done.

There were links with the local community that helped people to feel involved, empowered and valued. The provider worked with other organisations to improve the quality of the service and promote best practice.

31 January 2016

During an inspection looking at part of the service

This inspection took place on 31 January 2016 and was unannounced. At our last inspections on 24 November and 6 December 2015 we found continued breaches of regulations in relation to safe care and treatment, safeguarding and good governance. We served warning notices for these three continued breaches and asked the provider to make the necessary improvements by 18 January 2016. A warning notice is a formal way of saying to the provider that they were not meeting legal requirements and they needed to make improvements by a set date. At the last inspection we found a breach in relation to staffing which was too early for us to follow-up at this inspection. We will review this at our next inspection of the service.

Woodbury provides accommodation and personal care for up to 15 people with a range of learning disabilities, autistic spectrum disorders as well as physical disabilities. On the day of our visit there were 14 people living in the home.

There was no 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. The registered manager left in March 2015. The provider has appointed an acting manager whilst they undertook recruitment for a new permanent manager for the home.

We found that the provider had made all the necessary improvements to address the deficits we identified at our last inspection and so had met the requirements of the warning notices.

The provider had improved the way risks to people were managed. They had consulted with relevant healthcare professionals to ensure risks relating to moving and handling and pressure ulcers were assessed and addressed with suitable management plans in place. The provider had identified those people at risk of developing pressure ulcers and referred them for support from the district nurse who visited them regularly. Staff had attended refresher training in moving and handling and the provider had trained one staff to be the service’s ‘expert’ on moving and handling to support staff improve their practice. Training for staff on supporting people at risk from pressure ulcers was arranged for February 2016. The provider carried out checks that a person’s pressure relieving mattress was used correctly to reduce their risk of pressure ulcers. In addition the provider had consulted with a healthcare professional to ensure a person’s mattress was safe for use with their particular bed rails, so they could continue to use these items of equipment.

The provider had strengthened procedures for staff to record and report any injuries to people such as bruises or other wounds. Management investigated such injuries to check how they occurred and whether they were the result of abuse. Staff had also attended refresher training in safeguarding since we raised concerns at our last inspection.

The provider had improved the way they monitored, assessed and improved the quality of the service as well as record keeping systems.

24 November & 6 December 2015

During a routine inspection

This inspection took place on 24 November and 6 December 2015 and was unannounced. At our last inspection on 8 and 20 April 2015 we found the provider was breaching regulations relating to safe care and treatment, safeguarding, staff training and supervision, and good governance. After that inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. As part of this comprehensive inspection we checked whether the provider was now meeting these legal requirements.

Woodbury provides accommodation and personal care for up to 15 people with a range of learning disabilities, autistic spectrum disorders as well as physical disabilities. On the day of our visit there were 13 people living in the home.

There was no registered manager in post. The registered manager had left in March 2015 and a new manager was recruited shortly after. However, they had also left the service just over a week before our inspection. An acting manager was 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.

We found that the provider has not made all the necessary improvements to address the deficits we identified at our last inspection.

They continued to manage some risks to people poorly. These risks related to moving and handling, the prevention of pressure ulcers and bed rails. We found that risk assessments were not always carried out to assess risks to people and these were not always kept up to date with current information. Suitable risks management plans to guide staff were also not available.

People were still not safeguarded from abuse. Although staff recorded bruises and other wounds on body maps appropriately these were not investigated by management to check how they occurred so they could take appropriate action to prevent these from happening again.

There was insufficient numbers of staff deployed on shift to meet people’s needs. The provider’s recruitment campaign to fill vacancies continued.

The auditing systems in place remained ineffective in identifying the breaches of regulations we found during this inspection. In addition, records in relation to the management of the service were not always well maintained.

Medicines management was safe and our checks indicated people received their medicines as prescribed. The medicines policy had been updated to include how ‘homely remedies’, medicines purchased over the counter, should be administered safely. Staff carried out daily audits of medicines to check people had received their medicines appropriately.

Recruitment was safe and the provider had introduced checks of people’s mental and physical health to carry out their roles as required by law. Other checks on staff were carried out such as checks of criminal records, references from previous employment and employment histories, proof of identification and right to work in the UK. The provider had audited staff recruitment folders and identified some gaps and they were gathering the required information from head office or from staff to keep at the service.

The premises were safe because regular checks were carried out both internally and by external contractors. A maintenance team was in place to carry out day to day repairs which were requested and carried out promptly.

Staff received support to carry out their roles through supervision and a suitable training programme.

People received choice of food and drink and received food in sufficient quantities. People also received the right support to eat and drink and their nutritional status was monitored by staff through regular weighing where necessary. Staff supported people to access health services in order to remain healthy.

Staff understood their responsibilities in terms of obtaining consent from people and supporting them under the Mental Capacity Act 2005. The service was also meeting their requirements under the Deprivation of Liberty Safeguards (DoLS). These safeguards are there to help make sure that people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom.

Staff treated people with kindness, dignity and respect in their day to day interactions with them. Information about people’s preferences and backgrounds was recorded and people were involved in developing their care plans. Staff supported people to be as independent as they wanted to be.

A suitable complaints system was in place and relatives told us they were confident in how the provider would respond if they raised concerns with them.

People had individual activity programmes in place based on their interest and a range of activities were offered to people both inside and outside the home.

At this inspection we identified three continued breaches of regulations. These were in relation to safe care and treatment, safeguarding people and good governance. We are taking action against the provider in relation to these breaches and will report on this when our actions are completed. We also identified a new breach of regulation in relation to staffing. You can see the action we told the provider to take at the back of the full version of this report.

08/04/2015 & 20/04/2015

During a routine inspection

This inspection took place on 8 and 20 April 2015 and was unannounced. This was the first inspection since the service was taken over by Balance (Support) CIC and was registered with CQC in December 2014.

Woodbury provides accommodation and personal care for up to 15 people with a range of learning disabilities, autistic spectrum disorders as well as physical disabilities. On the day of our visit there were 15 people living in the home.

The registered manager had recently left the service and recruitment of a new manager was taking place while an acting manager was in charge. 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.

The service did not manage risks to people well. Risk assessments in relation to pressure ulcers, choking and to the provision of first aid were not always in place. In addition, staff did not always monitor people’s weight regularly when people developed nutritional needs to ensure they were eating and drinking adequately.

Medicines management was not safe. We could not always confirm people had received their medicines as prescribed through stock balance checks because the service did not keep accurate records of medicines in stock. Arrangements to ensure over the counter ‘homely remedies’ were administered safely were also not in place.

People were not safeguarded appropriately from abuse. This was because bruises and accidents and injuries were not always well recorded and investigated to check whether they occurred because of abuse. Accidents and injuries were also not analysed to check risks were being identified and managed appropriately.

Recruitment was not always safe because the provider did not ensure staff were capable of working with people due to any physical or mental health conditions. However, the service followed legal requirements in checking all other aspects of staff recruitment, such as references and criminal records checks, before they started work at the service.

The auditing systems in place were ineffective in identifying the breaches of regulations we found during this inspection. In addition, records in relation to the management of the service were not always well maintained.

Staff had not received regular supervision, although the provider was aware of this and was addressing this. Staff also did not receive regular training in topics to enable them to meet people’s needs. There was no policy in place which identified how often staff should receive training on the various topics, and staff received refresher training inconsistently.

Not all staff understood their responsibilities under the Mental Capacity Act 2005 in their day to day roles and there was no clear programme for training staff to ensure they had the necessary understanding of this act. However, the service worked with other organisations so that when people lacked capacity to make certain decisions, decisions were made for them in their best interests. The service was meeting their requirements under the Deprivation of Liberty Safeguards (DoLS). These safeguards are there to help make sure that people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom. The provider had assessed whether people required DoLS and made the necessary applications. In this way people’s rights in relation to this were recognised, respected and promoted.

A range of checks were in place to ensure the premises and equipment were safe and the home was well maintained.

People were provided with a choice of food and received appropriate support to eat and drink. Staff supported people to access health services in order to remain healthy.

Staff treated people with kindness, dignity and respect. Staff knew the people they were supporting well, including their preferences, communication styles and background and supported them to be as independent as they wanted to be. This information was all well documented in people’s support plans to guide staff in supporting people in the best ways for them.

The complaints system in place was followed in investigating and responding to complaints raised. People had access to advocates who supported them to make complaints about support they found unsatisfactory.

Staff supported people to access activities they were interested in and each person had an individual activity plan which they followed.

At this inspection we identified a number of breaches. These were in relation to safe care and treatment, safeguarding people, recruitment, staffing and good governance. You can see what action we told the provider to take at the back of the full version of the report.