Woodboro 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.

This is the first inspection for this service under the current provider.

This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 reported any safety events. The provider had systems in place to record individual incidents and accidents and completed a monthly audit to identify and address concerns. Actions and lessons learnt were shared with staff to promote learning and embed good practice.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. Processes were in place to support safe transitions for people being admitted into the service and moving between different health and social care settings. The provider shared information with the appropriate health professionals and we received positive feedback from healthcare partners about the positive impact this had on people’s continuity of care. One health professional told us the provider had adapted to changes to ensure “effective communication and continuity of care for residents.”

The provider worked with people to understand what being safe meant to them. However, the provider’s safeguarding processes were not always implemented robustly.

The provider had systems in place for identifying and reporting concerns to the local authority safeguarding team. However, we found they were not always clear on when corresponding safeguarding notifications should be raised with CQC. This meant, there was a small number of safeguarding concerns which had not been shared with CQC. Following our feedback, the provider confirmed they had reviewed and strengthened their safeguarding processes and submitted retrospective notifications where necessary.

Staff concentrated on improving people’s lives while protecting their right to live in safety, free from avoidable harm and neglect. Staff were aware of how to recognise potential signs of abuse and knew how to raise safeguarding concerns. There was a safeguarding policy and process in place and staff had received safeguarding training.
 

The provider worked with people 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.

Risks to people’s safety were assessed and people had relevant, personalised risk assessments in place. Whilst we found some people’s risk assessments were more detailed than others, staff were consistently knowledgeable about risks to people’s safety and understood how to keep them safe. People were supported by an established staff team who knew them well.

Following our feedback, the provider responded promptly to confirm they were reviewing the relevant risk assessments to ensure they were sufficiently detailed.
 

The provider’s processes for detecting and controlling potential risks in the care environment were not always robust. During the inspection we found not all environmental risks had been identified and addressed. For example, we found wardrobes which were not properly secured, flooring which may pose a trip hazard and unsafe items stored in an unlocked room which could be accessed by people living in the service. This meant people were exposed to potential risks as environmental hazards had not been effectively identified, assessed or mitigated.

The provider responded immediately during the site visit, arranging for items to be secured or removed. Following our site visit, the provider confirmed they had reviewed and amended their environmental monitoring processes to ensure more robust checks were implemented straight away.
 

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.

The provider had completed appropriate recruitment checks to ensure staff were safely employed. However, minor improvements were required in relation to checks on applicant’s employment histories and previous care positions. Following our site visit, the provider confirmed they had reviewed the relevant recruitment documentation to ensure all information was included.

People were supported by a consistent staff team. Relatives told us people had support from staff who understood their needs. Comments included, “The carers are regular”, “They’ve got to know [person]”, “They don’t have agency staff” and “The staff are very friendly. I’ve no concerns [on staffing].”
 

The provider had systems in place to monitor cleanliness, and we found the service was generally clean. However, we found the condition of some fixtures and fittings in the service did not promote good infection prevention and control. For example, we found stained and worn furniture and identified concerns with the condition of some flooring and walls. We also found some bathrooms were in need of renovation.

At the time of the inspection, the provider had a service improvement plan in place which identified planned refurbishments to the bathrooms and flooring. Following our feedback, the provider confirmed they had replaced some items of furniture and had a schedule for the replacement of the remaining stained and worn items.
 

The provider made sure people’s medicines were safe and met their needs. Medicines were well organised and safely stored with appropriate checks completed. People’s medicines were given in line with their individual needs and preferences.

We received positive feedback from people’s relatives about how well people’s medicines were managed. Comments included, “Medicines management is absolutely excellent”, “I am informed and consulted about any changes in medicines” and “The Home always informs me about [person’s] medication.”