Woodleigh Manor Residential Care 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

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 good. At this assessment, the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 81 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened, investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service demonstrated an open and reflective learning culture. Incidents, accidents, complaints and safeguarding concerns were analysed and discussed during handovers, flash meetings and senior communications. Learning was shared across shifts and provider locations. Additional internal, external and more specialist training with health professionals was sought to continuously upskill staff and improve the service. A staff member said, “We talk about incidents as a team and look at how we can stop it happening again, it’s about learning, not pointing fingers.”

Families were informed of incidents, accidents and safeguarding concerns at the earliest opportunity in line with the provider’s duty of candour responsibilities.

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.

Safe systems were in place to support people moving into, between and out of the service. Pre‑admission assessments were thorough, comprehensive and considered person-centred care, considering mental and social factors. For example, people’s needs were re-assessed at different times of the day to provide a fuller picture of people’s presentations to ensure the service could meet their needs and provide a forever home for everyone. Staff told us, “I love the teamwork we all chip in and help each other if needs be, just to ensure the residents come first.”

Hospital transfers were managed well, with detailed hospital packs prepared and people supported by staff who knew them well, minimising distress and risk/s for them during any transitions between services. A relative described this positively, saying, “When mum went to hospital, everything was organised and staff knew exactly what she needed.”

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.

Staff received safeguarding training and understood how to safeguard people from abuse. They were aware of the procedures for reporting internally and/ or externally to other agencies, when required. Safeguarding referrals and Care Quality Commission (CQC) notifications were made appropriately and efficiently. Staff described how they would report any concerns, “If something didn’t feel right, I’d go straight to the manager or report it outside if I needed, to the safeguarding team or to the Care Quality Commission.”

The Mental Capacity Act 2005 (MCA) provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take specific decisions, any made on their behalf must be in their best interests and as least restrictive as possible. We found the provider to be working within the requirements of the MCA.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty had the appropriate legal authority and were being met. DoLS applications had been submitted to the local authority for authorisation, in line with legal requirements.

Relatives felt the service was managed safely. Our observations of people showed they felt safe and staff regularly reassured them when necessary. The atmosphere was calm and relaxed throughout the inspection, including the staff’s demeanour when situations were at times more challenging.

The provider worked with people and/ their families to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments focused on enablement rather than restriction. The provider and registered manager supported people to go out into the community and continue meaningful activities whilst managing safety and respecting people’s rights to make unwise choices. For example, the registered manager told us, “They may be in a care home, but they still should be able to enjoy their life. I will put keycode in the door and let residents go out into the community. [Name of person] wanted to feel like they used to before, they wanted to go to the pub, play snooker and darts. They mix with others that play darts and do the quizzes. My team member just keeps a close eye whilst they engage with others, weighing up their own risks and enjoys their community visit.” Staff described how they would ensure the person was fully informed of the risks associated with any unwise decisions they might make. One staff explained, “Some like to make unwise choices, it’s still their choice. You can say it’s not good for you, how about some of this, but essentially you can’t deny them that. We try to empower with the knowledge and let them make their own decisions.”

The registered manager promoted and facilitated people being able to live their best lives as they chose to and described how they gradually worked towards removing any barriers people experienced. They explained, “Just because someone lives in a care home doesn’t mean they stop living their life. We manage risks so people can still do the things they love.” This approach meant staff worked hard to identify people’s aspirations, employment histories, hobbies and past lives so they could enhance their current lives with the things they still loved to do. For example, past employment activities, their favourite hobbies or exploring new activities they showed an interest in. Any risks were regularly reviewed as people’s needs changed and/or annually.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The registered manager completed daily walks around the service, to ensure it was safe, clean and well maintained. Fire safety systems, Personal Emergency Evacuation Plans (PEEPs), equipment checks and environmental audits were in place. Adaptations supported people’s safety whilst respecting personal choice, including decisions about personalised bedrooms. Ongoing refurbishment plans demonstrated a proactive approach to environmental improvements. A relative commented, “It always feels safe and clean when I visit.”

The provider had a fire safety action plan in place. The registered manager told us all the actions had been completed, but these had not been recorded as completed. The registered manager was in the process of updating this document to accurately reflect the works completed. An external company was due to visit to review and provide a further fire safety report. We requested a copy of this once it had been updated.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staffing levels were sufficient to meet people’s needs, including enhanced staffing for those requiring one‑to‑one support. Rotas were in place and a dependency tool used to calculate appropriate staffing levels and skill mix. We observed sufficient staff to meet people’s needs. Staff described good teamwork and access to support when needed.

Recruitment and pre‑employment checks were in place to ensure staff met the requirements needed to work within the care sector. Agency staff were kept to a minimum to maintain a consistent and familiar staff team for people. All staff received a comprehensive induction, ongoing training, refresher training and competency checks and they were able to request any additional training as and when required.

The registered manager supported staff on the floor, during group and one on one discussions. They kept an open-door policy to provide ongoing support to staff, including out of hours phone calls. A staff member said, “There’s always enough staff, and we help each other.”

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.

Infection prevention and control practices were effective. Staff demonstrated good knowledge of PPE usage, hand hygiene, what to do to in the event of an outbreak including any waste disposal. The environment was visibly clean, and audits showed compliance with IPC standards. Learning from external audits was shared and used to support improvement. A relative said, “The cleaners are always around, and it never smells – it feels hygienic.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines were managed safely, with trained senior staff administering medicines in a person‑centred way. Body maps were in place for the recording of patch applications. Covert administration plans were detailed, and best interest decisions had been completed and recorded health professionals, people and their family’s input. A relative said, “I’ve never had any worries about how medicines are handled.”

The service was conscientious not to over medicate people that presented with more complex needs. As and when required medicine (PRN) protocols were in place. Where PRN medicines were used to manage behaviours, these were only used as a last resort and often other least restrictive measures worked without the need for these to be administered. One relative advised, “Staff discuss any changes of[name of person]medicine with me. In the last care home, they were giving them as and when required lorazepam but here they are not generally giving lorazepam.” This had been recognised as ineffective for its prescribed use on admission to the service and its usage significantly minimised.

We identified a couple of minor medicines issues; the provider took steps to resolve these during our inspection, such as, prescription labels for creams were non-specific. Staff knew where to apply these creams, but the labels did not confirm where they were to be applied. The registered manager contacted the prescribers to ensure future labelling was detailed and clear to follow.