Woodfield Care 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 inadequate. At this assessment 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 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. We found incidents were managed and reviewed appropriately, and outcomes shared. Staff understood how to identify incidents and escalate them in a timely and appropriate way. One told us, “I'd inform the [registered] manager and update families.”

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.

Although some processes were in place to support people during changes in their care, we found evidence records were not always updated promptly when people’s needs changed, which increased the risk of unmet needs.

Transitions between staff teams and shifts were not always supported by robust information sharing processes. Most staff told us there were handovers in place at the beginning of their shift; however, others told us they didn’t receive a handover because they worked part-time hours and relied on a senior being available to share information about changes to people’s care needs. This limited the provider’s ability to ensure people received safe, person‑centred care continually.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always 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 always share concerns quickly and appropriately.

We found insufficient oversight of safeguarding concerns and systems were not operated effectively. Although we saw evidence of some safeguarding concerns being reported to the local authority, the Care Quality Commission (CQC) was not always notified, which is a legal requirement.

Staff had completed safeguarding training, knew how to identify the different types of abuse and how to escalate any concerns appropriately.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We reviewed whether the service was operating in line with MCA principles and how DoLS were managed. Where people lacked capacity to make specific decisions, applications for DoLS had been submitted as required.

The provider did not always work effectively with people to understand and manage risks. Staff did not always evidence that care was delivered in a way that consistently met people’s safety needs. Following changes in people’s needs, care plans did not always contain consistent information, for example in relation to people’s weights. Records did not always demonstrate people had been weighed in line with their assessed needs and there was evidence of inconsistent documentation of weights, which impacted on auditing systems. This increased the risk of unsafe care delivery, especially for people who required regular weight checks as part of their malnutrition risk and air mattress calculations to manage risks associated with skin integrity.

Inspectors identified 2 people whose call buzzers were not within their reach and 1 which was not working. We raised this with the registered manager who acted immediately to address all concerns raised and assure inspectors people were safe. In addition, further checks were implemented and lessons learnt produced to share with staff.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Most areas of the service were being maintained; however, we found some concerns with call buzzers not working correctly, the service lift being faulty, and fire evacuation doors not fitting door frames adequately. People using the service and their relatives told us they were generally satisfied with the environment; however, some feedback indicated the lift had been out of use for an extended period, and this was impacting people within the service. The provider carried out other building safety and equipment checks, including gas, fire, and electrical inspections, to ensure the safety of people living in the service. These records were satisfactory. During the assessment, the provider took prompt action to address the shortfalls identified and provided assurance contingency plans were in place in respect of the lift concerns.

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.

People’s relatives told us staff had the skills and knowledge to care for their loved ones, and there were enough staff on duty to meet their needs.

Observations confirmed staff were available both in communal areas and to support people who were cared for in bed. Feedback from relatives confirmed this. Staff told us there was not a high turnover of staff.

Staff had been recruited safely and received ongoing training to ensure they remained competent. We identified an issue with the competencies of agency staff which we raised with the registered manager. Immediate actions were taken to ensure future competency checks included agency staff.

Staff told us they had regular supervisions and appraisals which were useful and in line with the service’s policy.

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.

Improvements had been made to the management of infection prevention and control (IPC). Processes were in place and staff were clear about their responsibilities to act if they noticed any concerns in relation to infection control.

Monthly audits were undertaken and any concerns were addressed within appropriate timescales to meet compliance.

Staff had received IPC training, had access to appropriate Personal Protective Equipment (PPE) and cleaning products were seen to be stored safely. Communal areas and bedrooms were clean and smelt fresh.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. However, staff involved people in planning, including when changes happened.

We reviewed medication records and found stock counts for 2 people’s medicines did not match administration records. This meant we could not be assured this person received their medicines as prescribed. Audits had been carried out but were not robust enough to detect these errors.

When people used ‘as required’ medicines (PRN) we identified not all protocols were in place to ensure these were administered consistently and when people needed them.

We identified 2 people with longstanding prescriptions for medication which had not been reviewed.

Controlled drugs, which are subject to specific storage and recording guidelines were managed in line with good practice guidance.

We raised concerns with the registered manager who took immediate action to address.