Woburn 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 that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question good. At this inspection, the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 59 (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 always identify where concerns needed to be reported to CQC in line with statutory guidance and legislation. There were several occasions where people had hurt themselves seriously or put themselves or others in danger, requiring support from health professionals or the police. The management team acted to retrospectively report these and to review all incidents to help make sure they did not need to be reported. Whilst the management team were monitoring some people to see if there were trends to incidents where support could be put in place this was not happening consistently. This limited the opportunities for staff to learn and identify from incidents. The management team took action to improve however we could not be assured this would have happened were it not for our direct feedback during the inspection.

Despite these findings, most incidents had been reported to the safeguarding team. Staff recording of incidents was very detailed, explaining clearly how people were supported by staff during these times. Learning from incidents was shared with staff during meetings to help promote learning. One relative said, ‘‘If something needs changing then the staff are quick to pick up on it and get it sorted out. They are very good and reassuring like that.’’

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 contacted professionals such as GP’s or psychologists if people needed support. If professionals gave advice that needed to be followed, this was communicated and shared with the staff team. Staff shared important information about how people wanted to be supported with partners and professionals to help ensure safe transitions. One relative said, ‘‘[Staff] are very good at getting [family member] to their health checks and appointments, which is something they have found difficult in the past.’’

People were protected from abuse and improper treatment. Safeguarding concerns were taken seriously and investigated. However, the management team did not always report concerns to the safeguarding team where necessary and reviewed outcomes to see if lessons could be learned. They reported these to the safeguarding team retrospectively during our inspection

Staff were trained in safeguarding and knew how to report concerns. One person said, ‘‘It is safe living here. Staff listen and if I am in danger they say, ‘no [name].’’ The person then laughed. Other people showed how safe they felt being supported by staff by being relaxed whilst staff helped them. People smiled as staff supported them and gave signs, they felt safe. A relative told us, ‘‘I am very sure that [family member] is safe and have complete confidence the staff team would speak up if they were not.’’

The provider worked well with people to understand and manage risks. However, risk assessments and care plans were very mixed in the level of detail they gave to guide staff how to keep people safe. For example, some care plans informed staff to ‘use distraction techniques’ to help a person feel better if they were upset but did not detail what these techniques were. Some care plans stated people would be able to tell staff if they felt unwell, when this is not something they could have done easily. The management and staff team did not use physical restraint to support people, however several care plans stated this could be used. This increased the risk of people being supported with a technique that was not suitable for them. The management team took our feedback seriously and updated care plans and risk assessments based on our findings. We recieved 2 updated care plans following our feedback to the provider. These contained more detail and guidance about how staff could best support people.

Other care plans and risk assessments were much more detailed. Staff knew how to keep people safe and were knowledgeable about the risks people faced and how best to mitigate these. A person showed us how happy they were that staff were able to safely support them to use their kitchen. A relative told us, ‘‘The staff team are very determined and dedicated to make sure [family member] can still do what they want and stay safe at the same time.’’

The provider took action to deal with potential risks in people’s home environments. Most environment related risks reported by staff were rectified by the provider who supported people by contacting their landlords. The management team were taking action to liaise and communicate with landlords who understood how best to support people in supported living settings. Staff supported people to keep their home environments tidy and free from risks. Equipment used by people was checked to ensure it was safe to use. Fire safety was well understood by the management and staff team and detailed plans were in place to support people if there was an emergency relating to fire.

The provider was not ensuring all the appropriate checks were in place to ensure staff were suitable for their job roles before they started work. We checked staff files and found gaps in employment history and no evidence a robust interview process had happened when staff started working at the service. The management team rectified the gaps in employment histories during our inspection.

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. There were enough staff to support people with their needs such as personal care and eating and drinking. Staff told us they had time to chat and engage with people as well as support them with their essential care needs. Most people using the service had 1 to 1 staff support, and we observed staff make every effort to spend time and engage with people throughout the day. Staff were trained in all areas relevant to their job roles and were confident and knowledgeable about this. One person said, ‘‘I like all the staff. Yes!’’ A relative told us, ‘‘The staff team has been very consistent the last few years, so I think they are well looked after. It’s great for [family member] as they really have got to know and understand them well.’’

The provider assessed and managed the risk of infection. Staff were trained in infection and prevention control (IPC) and told us they had the necessary equipment to help people keep their homes clean. We observed people’s homes to be clean. Staff supported people to take part in cleaning some areas of their home if they chose to do so. Audits and checks were in place to monitor the cleanliness of people’s homes and the effectiveness of the IPC measures in place. Staff showed us evidence of people being supported to clean their homes and it was clear they enjoyed doing this.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. People received their medicines on time and staff knew how people liked to be supported with them. Staff were trained to administer medicines and had their competency to do so checked regularly. People who were prescribed ‘as and when required’ (PRN) medicines had detailed guidelines in place so staff could administer them safely. Staff fully understood PRN medicines to support people when they felt unhappy or angry were to be used as a last resort. They support people without using PRN medicines very successfully. Audits were in place to help ensure medicines were administered safely. One relative told us, ‘‘I am happy that staff work to try and reduce the number of medicines [family member] is taking. They feel much better as a result.’’