Woodleigh Rest 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 changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, staffing and recruitment at the service.

This service scored 31 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Events had not been effectively and robustly reflected upon and used to drive improvement. There was a lack of oversight and monitoring of lessons learnt. For example, not all accidents and incidents were reflected in the monthly audit, lessons learned were limited and themes and trends such as times, location and whether falls were witnessed or unwitnessed were not explored. Safeguarding audits did not capture all safeguarding incidents.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Whilst the service worked in collaboration with other stakeholders and involved some health professionals, robust records of this were not always maintained. This meant it was difficult to audit and fully understand the care and treatment people had received, or to identify when professionals made recommendations. This placed people at risk of poor care.

The provider did not work effectively with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not identify and share concerns appropriately.

Records showed some safeguarding incidents had been referred to the local authority and notified to the CQC. However, people’s care records identified other incidents including unexplained bruising and skin tears which had not been shared.

Staff had received safeguarding adults training and the provider’s safeguarding policy had been updated. However, signs of abuse were not always recognised or reported in accordance with the provider’s policy.

The provider did not work well with people to understand and manage risks.

Risks to people’s health and safety were not effectively assessed, monitored and mitigated. No risk assessments were in place for people who had bed rails. For example, 1 person had bed rails in place which did not extend the full length of the bed, placing them at risk of injury or entrapment. Care records showed the person had been found trying to get out of bed; however, no assessment had been carried out to determine whether bed rails were safe or suitable to use.

There was no risk assessment in place for another person who had a free-standing oil heater with a very high surface temperature in their bedroom. The heater was placed close to the person posing a potential risk of harm or injury. This was repositioned when we alerted the registered manager.

Not all staff had taken part in fire drill training. Records showed 3 fire drills had been carried out since the beginning of 2024; however, no night staff had participated. This placed people, staff, and visitors at risk of harm in the event of a fire.

The provider did not always detect and control potential risks in the care environment. They did not make sure that the environment, equipment and technology supported the delivery of safe care.

We found environmental risks had not been identified or addressed, which placed people at risk of harm or injury. For example, 1 mobile person had been admitted to a room which had a broken bath panel that had jagged edges and a missing floor tile. Another mobile person had wires trailing across their bedroom floor posing a trip hazard.

Sensor equipment was used in most bedrooms to alert staff when people were mobile. However, this was not linked to the call bell system, meaning the alarms could only be heard in the area where the sounding devices were located, on the ground floor of the home. If staff were not present in this area, they would not be aware the sensor had triggered, placing people at potential risk of harm or injury.

People in the lounges were unable to summon help from staff via the call bell system, as the call bells were not accessible. One person told us, “If I want anything at night I have a buzzer in my room, but if I want anything like now [in the lounge] I just shout.”

The provider did not make sure there were enough qualified, skilled and experienced staff to meet people’s individual needs and provide safe care.

People, relatives and staff raised concerns about the staffing levels, particularly at nights and weekends. Comments included, “There doesn’t seem to be enough staff. Weekends are worse. There’s only 4 of them and they don’t watch them [people] in the dining room. There’s not anyone supervising mealtime and they [people) could choke. I worry about that” and “[The staff] can’t spend a lot of time with you because they have plenty to do.”

Duty rotas showed there were 4 care staff on duty each day, although at the weekend this reduced to 3 care staff between 1pm and 3pm. No kitchen staff were employed as ready meals were provided, so 1 of the 4 care staff was allocated to meals and drinks. At the weekends, there were no laundry, domestic, maintenance or management staff on duty. At night there were 2 staff on duty for 23 people accommodated over 2 floors. Night staff were also required to complete laundry and cleaning tasks.

The dependency tool used to calculate safe staffing levels had not been completed correctly and did not accurately reflect the needs of each person. Environmental factors had also not been taken into consideration.

The deployment of staff was not always effective, and we had to intervene at times and alert staff to the needs of people in communal areas.

Recruitment processes were not robust as some required checks had not been completed to ensure new staff were safe to work at the service. For example, there was no evidence to show the outcome of a criminal record check for 1 staff member. Another staff member had gaps in their employment record which had not been explored. References for both staff members had not been verified.

The provider had effective infection prevention and control (IPC) measures in place to keep people safe.

The home was clean and hygienic. Staff had received up to date training in IPC. Supplies of personal protective equipment (PPE) were available throughout the service, and we observed staff using PPE appropriately and following good hand hygiene processes.

The provider’s IPC policy had been updated since the last inspection, and regular IPC audits were carried out to monitor cleanliness and infection control practices. No concerns were raised by people or relatives regarding the cleanliness of the service.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines were stored securely; however, not all areas used to store medicines were being monitored and when temperatures were recorded, they were not always documented correctly. This meant we were not assured medicines were stored at the recommended temperatures.

We found powder used to thicken drinks to prevent choking was stored securely, however staff did not always document when it had been added to drinks. Therefore, we could not be assured drinks were always being thickened safely for people.

For people whose medicines were administered covertly (hidden in food and drink) instructions from a healthcare professional were not always in place to ensure these were given safely.

People’s care plans did not always contain the information needed for staff to keep people safe. For 1 person who was prescribed an anticoagulant, there was no alert or risk assessment for staff on the risk of bleeding. For another person, who was prescribed a flammable cream, the care plan contained no reference to this despite their smoking status.

There was person-centred information available for people prescribed medicines ‘when required’ to manage their agitation. However, the reason for administration had not always been recorded on the care system when the medicine had been given. Staff did not always document the outcome or effectiveness of using medicine to manage agitation.

The time a medicine was administered was not always documented for time sensitive medicines. For 1 person the 4-hour time interval between medicines containing paracetamol had not been observed so there was an increased risk of side effects.

People’s medicine records contained information on allergies and there was information for staff on how people liked to take their medicines. Medication administration records for topical preparations such as creams were completed. Medicines were managed by staff who had been trained and had their competency assessed.