Woolston House

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 people were protected from abuse and avoidable harm. This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider had systems in place to ensure any incidents/accidents or complaints were, recorded, investigated and acted upon. The management team analysed these to identify any themes or whether further action was required. Any lessons learnt were shared for improvement with the staff team. A summary of incidents, with an overview of lessons learnt was displayed in the reception area. The management team shared information such as safety or medication alerts within staff meetings.

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.

Staff worked with other professionals to ensure continuity of care when people transitioned into the service. People were supported, sometimes through day visits or longer transition periods. Important Information was contained within people’s care records, which could be shared easily, for example, if someone went into hospital.

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 had completed safeguarding training and understood what to do if they had any concerns abuse or neglect was occurring. The management team reported safeguarding concerns to the local authority as required. Where required, Deprivation of Liberty (DoLS) authorisations had been applied for or authorised.

People felt safe living at the service. Comments included, “I do feel safe here” and “He is safe there and he gets on with the staff team he has.” The provider had recently opened a 4th unit, and in consultation with people, the management team had reviewed the mix of people in line with their needs. Several people had been supported to move units and for most this had been positive, supporting them to feel safe.

The provider worked with people to understand and manage risks. Whilst staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them, some aspects of risk had not been fully assessed.

Overall, staff assessed potential risks to people, and took actions to mitigate risk, such as providing sensor equipment. However, we found staff had sometimes not followed plans in place. For example, plans to reduce the risk of pressure ulcers included the use of equipment, such as air mattresses. One person’s mattress was incorrectly set, but staff had not identified this despite records showing it had been checked. A broken cupboard lock in a communal kitchen meant thickening powder was not stored safely. The registered manager addressed this immediately.

Various assessments relating to risks within the environment had been undertaken. Whilst staff had considered potential risks relating to people who were living with dementia having access to toiletries or food/fluid if they required modified diets, the outcomes had not been fully recorded. The registered management told us they would rectify this.

Following a recent incident, further risk assessments needed to be undertaken and recorded for one person, and we were advised the provider’s Behaviour Support Team were supporting with this.

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 environment was safe and well maintained. The provider employed a maintenance person who undertook health and safety checks, including fire safety. The management team were considering further options for input with redecoration, as some paintwork needed a refresh. Contractors were fitting a new floor in one of the dining rooms.

The provider had a Health and Safety Team who provided updates about best practice.

Personal emergency evacuation plans (PEEPS) were up to date and accessible in the event of an emergency through handheld devices. Due to recent changes in the units and staffing, regular fire drills and evacuations were being prioritised.

Following a fire risk assessment, most required actions had been completed. Two outstanding actions were in progress and within timescales for completion.

The provider was working to ensure there were enough qualified, skilled and experienced staff. They ensured staff received effective support, supervision and development.

Staff were responsive to people, and said they were able to meet their needs. We received mixed feedback from people and staff in relation to staffing numbers. Some people were given one‑to‑one support as part of their care. The provider had recently opened a 4th unit, and staffing numbers had changed based on the dependency of people’s needs, in consultation with the local authority. People told us, “Sometimes they are quick to help, but it depends on the numbers” and “You always have to wait for assistance.” Some staff felt staffing levels were sufficient. Others felt people’s needs were met but they sometimes had to wait, especially at night. The registered manager had reduced the amount of agency staff used and several staff had been recruited. The management team were overseeing the service while the new staffing arrangements became established.

Staff told us they felt supported and were offered supervision meetings and received performance reviews. The registered manager kept oversight of these, and recent work had been undertaken to support line managers to ensure these were carried out effectively and in line with policy. Various staff meetings had been held but some staff said they had not been involved in a wider staff meeting.

Staff were recruited safely and received suitable training. The provider had an in-house training team, and new staff completed a comprehensive induction and had a buddy for support. One staff member said, “We did 4 weeks induction at the start, it's the best training I've ever had.” Staff undertook mandatory role specific and clinical training. The provider offered further training to support staff development.

Staff undertook positive behaviour support training to help them provide person centred care and learn techniques to respond safely to distressed behaviours. However, not all staff who were required to complete this training had done so. The provider confirmed this training was planned for all staff to complete it.

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.

The home was clean and odour free. The provider ensured regular infection prevention and control (IPC) audits were undertaken and had appointed an IPC champion. Staff had received relevant training and had access to an adequate supply of PPE.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Systems were in place to ensure people received their medicines as prescribed. Staff received training and checks to ensure they had the knowledge and skills needed to manage and administer medicines safely.

We identified a minor recording issue in relation to controlled medications (CDs), and whilst secure, some medicines were not stored fully in line with the provider’s policy. The management team rectified this straight away and put some further spot checks in place.