Background to this inspection
Updated
8 December 2021
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection visit on the 24 August 2021 was carried out by two inspectors. On the 31 August 2021 one inspector returned to the service. The analysis of the evidence sent to us concluded on the 22 September 2021.
Service and service type
Woodlands Retirement Residence is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.
During the inspection-
We spoke with eight people who used the service about their experience of the care provided. We spoke with eight members of staff including the registered manager, who is also the registered provider, the deputy manager, care workers and the chef. We spoke with one visiting healthcare professional. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
We reviewed a range of records. This included eight peoples care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service including policies and procedures were reviewed.
After the inspection –
We continued to seek clarification from the provider to validate the evidence found. We looked at training data and quality assurance records.
Updated
8 December 2021
About the service
Woodlands Retirement Residence is a residential care home providing personal care to 18 people aged 65 and over many of whom live with dementia at the time of the inspection. The service can support up to 19 people.
The care home accommodates people in one adapted building over two floors. Both floors of the home were accessible via a lift.
People’s experience of using this service and what we found
We found some areas of people’s care experience which could be improved further. For example, people were not always informed what meal they were receiving. In addition, there were periods of time where people did not receive meaningful engagement or opportunity for activities.
Improvements had been made in the monitoring systems in place at the service. However, we found that these had not consistently been utilised and had not identified some of the areas of improvement we identified at this inspection. Further time was needed to ensure these new systems were embedded.
People were supported by staff who understood how to recognise and escalate safeguarding concerns should they have any. Peoples’ medicines were in the most part given safely and staff had received training around the administration of medicines.
People were supported by staff who had received sufficient training for their roles. Staff had been recruited safely and received an induction and supervision.
People had the risks associated with their care managed well and steps were put in place to mitigate these. People received access to healthcare to support their individual needs.
There were parts of infection control practice that needed improving. We observed two staff not wearing face masks and some staff not wearing face masks appropriately. The provider has informed us they have taken action to address this practice.
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.
Staff enjoyed supporting the people at the home and we saw that staff engagement with people was caring and kind.
People had a care plan that reflected their individual needs and which was reviewed to ensure it remained current.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection (and update)
The last rating for this service was requires improvement (published 21 December 2020). However, the service was placed in special measures as they had been rated ‘Inadequate’ for two consecutive inspections in one key question. We found that there was a breach of Regulation 17. Following this inspection we met with the provider and carried out monthly meetings to monitor and support improvement in the service.
This service has been in Special Measures since 21 December 2020. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
At this inspection improvements had been made although these needed to be sustained and embedded and as such the provider was still in breach of regulation 17.
Why we inspected
This was a planned inspection based on the previous rating and to see if the required improvements had been made. This inspection was also prompted in part due to concerns received about people having choices in their care, people not being supported safely with manual handling and people having routines for when they had drinks and food. A decision was made for us to inspect and examine those risks.
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.
Whilst we found the service had made improvements we have found evidence that the provider needs to make further improvements. Please see the safe, caring and well led sections of this full report.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.
This inspection has identified a continued breach relating to monitoring systems at the service. We will continue to monitor the improvement within the service through existing conditions we have placed on the providers registration. This includes sending us monthly reports of action the provider has taken to monitor and make improvements within the service.
Follow up
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.