Woodchurch House

Woodchurch House is a residential care home providing personal and nursing care for up to 60 people. The service supports people with a range of nursing needs including people living with dementia. The service is arranged across 2 floors with lift access. The second floor is mainly for people living with dementia. People had access to shared lounges and dining rooms and accessible bathrooms, gardens and grounds. At the time of our inspection there were 32 people using the service.

Woodchurch House also provides personal care for people living in their own homes, within the same accommodation. These people have a tenancy agreement and a separate agreement for their care provision. There were 43 people receiving personal care in their ‘own homes’. People receiving personal care can choose to have their care provided by another care provider. However, everyone living in Woodchurch House had their care provided by staff employed by the service. The manager confirmed that everyone received the same level of care and support, so we included everyone in this inspection. We are working closely with the provider to reduce the number of people with tenancies to enable the whole service to be available for people who require accommodation with nursing or personal care.

People’s experience of using this service and what we found

People and their relatives told us they felt safe and were happy living in Woodchurch House. One person said, “Yes, I’m safe, I’m well looked after, and my room is lovely and clean.” A relative told us, “It is safe, because it is well run, with plenty of staff and it is clean.”

People’s risks had been assessed and documented and staff knew people well. Staff knew about the individual risks and what to do to keep people safe. Risk assessments were reviewed regularly. The service was clean and infection control was managed well.

People were protected from the risk of abuse by staff who were trained in safeguarding processes. Staff were confident to report concerns and said actions would be taken as appropriate. Medicines were managed well, and lessons were learned and shared if something went wrong.

People were involved in decisions about their care, and they received care which promoted their dignity and encouraged independence. Relatives told us they were kept up to date with any changes in their loved one’s condition. One relative said, “They always let me know if they have called the doctor.”

People and their relatives spoke highly of the staff, describing them as kind, caring and friendly. Staff enjoyed working at Woodchurch House and told us teamwork was good.

Quality assurance processes were in place to monitor the service and regular audits were undertaken on a range of aspects, such as medicines and infection control. A new manager was in post and staff told us they found them approachable and supportive with an open-door policy.

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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 15 September 2021).

Why we inspected

This inspection was prompted in part by a review of the information we held about this service and in part by a notification of an incident following which a person using the service sustained a serious injury. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of unwitnessed falls. This focused inspection looked at the key questions of safe, caring and well led and examined those risks.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe section of this full report.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service remains good.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Woodchurch House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Woodchurch House is a residential care home providing personal and nursing care for up to 78 people. The service is also registered as a supported living service, a domiciliary care service and an extra care housing service. It can accommodate older people and people living with dementia. It can also provide care to people who misuse drugs and/or alcohol, people who need support to maintain their mental health and people who have physical and/or sensory adaptive needs.

At the time of the inspection there were 76 people living in the service, 16 people were receiving accommodation with personal and nursing care and 60 people were using the supported living service, rented their accommodation and had tenancy agreements with Woodchurch House Limited. These people could choose which provider delivered their care. All the people using the supported living service had chosen to receive their nursing and personal care from nurses and care staff employed by Woodchurch House. The manager confirmed everyone living at the service was entitled to the same level of 24-hour care, therefore we included everyone living at the service in our inspection. No one living in Woodchurch House was using the domiciliary care service or the extra care housing service.

The accommodation was provided across two floors, the second-floor accommodated people living with dementia. Each person had their own bedroom with private bathroom. There were communal lounges and bathrooms available on each floor.

People’s experience of using this service and what we found

People told us they felt safe in the service, staff were kind to them, and they liked living there. One person said, “I’m at home here and have my own bedroom. And that’s my space.” Another person said, “I’m fine here. It took some getting used to at first, but everyone is so kind to me, I like it here.” A relative said, “The staff at Woodchurch House are very kind and friendly and offer comfort to my [relative].” Relatives were reassured by the secured keypad entry to the property. Staff completed safeguarding training, and this was up to date. Risks were managed and people received safe care and treatment. Medicines were managed in line with national guidance and lessons were learned when things went wrong.

There was a new manager in place who had an open-door policy and was committed to continual service improvement. Staff found the management team approachable and supportive. Relatives had received communication about the new manager. There were comprehensive quality assurance processes in place to monitor all aspects of the service, overseen by a regional compliance manager.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 28 March 2020).

Why we inspected

This inspection was prompted by our data insight that assesses potential risks at services, concerns in relation to aspects of care provision and previous ratings. As a result, we undertook a focused inspection to review the key questions of safe and well-led. This enabled us to look at the concerns raised and review the previous ratings.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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.

The overall rating for the service remains good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Woodchurch House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Woodchurch House is a service providing personal and nursing care for up to 60 people. The service is provided in one adapted building set over three floors with a communal lounge, activity and dining area. At the time of our inspection 60 people were living at the service.

Some people living at the service had tenancy agreements with the registered provider and as such fell under the regulated activity of personal care. However, staff confirmed that everyone living at the service were entitled to the same level of 24-hour care, therefore we have included everyone living at the service in our inspection.

People’s experience of using this service and what we found

People and their relatives told us they were safe and well cared for at the service. Staff understood their responsibilities in relation to safeguarding people. Risks to people were assessed and staff had guidance to minimise risks. People were supported to have their medicines in the way they preferred and as prescribed. Systems to manage infection control were effective. Accidents and incidents had been reviewed for learning and to reduce the risk of them happening again.

There was a clear culture which focussed on people receiving person-centred care. People, staff and relatives told us the manager was approachable and was open to their views and ideas. Regular audits were completed to monitor the quality of the care provided. These were used to drive improvement. Staff worked closely with other professionals to ensure people’s needs were assessed and met. There were enough staff to keep people safe and they were recruited using processes which ensured they were suitable for their role.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 28 March 2020).

Why we inspected

We received concerns in relation to the number of safeguarding incidents and complaints the service had received. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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 coronavirus and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Woodchurch House is registered as a supported living service care, a care home with nursing, a domiciliary care service and an extra-care housing service.

A supported living service provides care and support to people living in supported living settings so that they can live as independently as possible. Under this arrangement people's care and housing are provided under separate contractual agreements. An extra care housing service provides care and support to people living in 'extra care' housing. Extra care housing is purpose-built or adapted single household accommodation in a shared site or building. The accommodation is bought or rented and is the occupant's own home. In both supported living services and extra care housing services people's care and housing is provided under separate contractual agreements. In a care home with nursing service people receive accommodation, nursing and personal care as a single package under one contractual agreement. A domiciliary care agency provides personal care to people living in their own homes.

Woodchurch House can provide accommodation, nursing and personal care for 78 people. It can accommodate older people and people who live with dementia. It can also provide care for people who misuse drugs and alcohol, people who need support to maintain their mental health and people who have physical and/or sensory adaptive needs.

At the inspection there were 73 people living in Woodchurch House. Three people were using the care home with nursing service and were funded by a health authority as they needed complex nursing care. The remaining people used the supported living service, rented their accommodation and had tenancies with Woodchurch House Limited. These people could choose which provider delivered their care. All the people using the supported living service had chosen to receive their nursing and personal care from nurses and care staff employed by Woodchurch House Limited.

No-one living in Woodchurch House was using it as a domiciliary care service or as an extra-care housing service.

The accommodation was provided on two self-contained floors comprising a number of bedrooms, communal bathrooms and lounges. Each person had their own large bedroom and private bathroom. There was no physical separation between the accommodation used for the supported living service and the care home service. A person using the care home service may have their bedroom next door to a person using the supported living service and both people may use the same communal lounge.

People's experience of using the service and what we found

People and their relatives were positive about the service. A person using the supported living service said, “I get on fine with the staff here. They’re kind to me.” In a thank-you card a relative said, "Bless you and thank you for your love and care mum received. I was always impressed with the hard work and standard of Woodchurch House.” Another relative said, “When my family member has been unwell and I’ve got upset the care staff have been wonderful and kind to me so I’m reassured. They’re like my daughters.”

The inspection of Woodchurch House was prompted in part by notification of an incident when a person using the service had an accident while being helped to transfer using a hoist. The person fell and sustained a serious injury. The incident was investigated by the local safeguarding of adults authority who concluded the accident was the result of an isolated example of neglectful care. At this inspection suitable steps had been taken to reduce the likelihood of the same thing happening again.

People received safe care and treatment in line with national guidance from nurses and care staff who had the knowledge and skills they needed. There were enough nurses and care staff on duty and safe recruitment practices were in place. People were helped to take medicines in the right way and hygiene was promoted to prevent and control infection. People had been helped to quickly receive healthcare attention when necessary.

People were supported to have maximum choice and control of their lives and nurses and care staff supported them in the least restrictive way possible and in their best interests. The policies and systems in the service supported this practice.

Most of the accommodation was adapted and maintained to meet people’s needs and expectations. Steps were being taken to address a small number of defects.

People were treated with kindness and compassion, their privacy was respected and confidential information was kept private.

People were consulted about their care and had been given information in an accessible way. People were supported to avoid the risk of social isolation by pursuing their hobbies and interests. Complaints had been resolved and people were treated with compassion at the end of their lives.

There was a service manager who was applying to become the registered manager. The service manager was a nurse. Quality checks had been completed and people had been consulted about the development of the service. Regulatory requirements had been met, good team work was encouraged and joint working was promoted.

For more details, please read the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service at the comprehensive inspection completed on 11/14 December 2018 was Requires Improvement (inspection report published 26 March 2019) and there were four breaches of regulations. The registered provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection enough improvement had been made and the registered provider was no longer in breach of regulations.

Why we inspected

The inspection of Woodchurch House was prompted in part by notification of the incident described above when a person sustained a serious injury.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our reinspection programme. If we receive any concerning information we may inspect sooner.

Woodchurch House is registered as a domiciliary care service and a care home. A domiciliary care agency provides personal care to people living in their own homes. Under this arrangement people's care and housing are provided under separate contractual agreements. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. In this case the Care Quality Commission regulates both the premises and the care provided, and both were looked at during this inspection.

Woodchurch House is registered to provide nursing, personal care and accommodation for up to 60 people, and at the time of the inspection there were 57 people living there. Most people were receiving personal care from staff and had rented their accommodation within Woodchurch House. They also received support from nurses who were employed by the registered provider under a separate agreement. It was arranged over two floors, with each floor having its own communal lounge area.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Woodchurch House was last inspected on 16 and 17 October 2017. We found continued breaches of legal requirements in relation to Regulation 9, 12, 17, 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one other breach found in relation to Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

After the inspection the provider sent us an action plan which detailed how they planned to address the breaches of regulations.

At this inspection we found that the provider and registered manager had made improvements to the service. However, further improvements were needed in three of the five domains.

Action was not always taken to protect people from risks. There were insufficient risk assessments in place to manage the risks of smoking at the service and national best practice guidance had not been followed.

People were put at risk from abuse. The registered manager had not followed up on all safeguarding concerns reported to them and the registered manager had failed to notify us of a notifiable event in a timely manner.

Effective systems were not in place to consistently assess, monitor and improve the quality and safety of the service. The provider had made some improvements to systems. However, these had not been fully embedded, which meant further improvements were required.

People's care plans had been reviewed and updated to ensure that their care and support needs were clear and their preferences were known. However, not all care plans consistently reflected each person's specific healthcare need.

People's needs were assessed and their care was delivered in line with current legislation.

People were supported to eat and drink enough to maintain a balanced diet.

Referrals were made to health professionals such as GP’s and speech and language therapists.

There were enough staff to meet people’s needs. People were responded to in a timely manner and staff could spend time with people.

Staff were recruited safely. Staff received training which ensured they had the skills and knowledge to deliver effective care.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People received their medicines safely. People were protected by the prevention and control of infection. The service was clean and smelt fresh.

People received care that was responsive to their needs. Relatives told us they knew how to complain if they had any issues or concerns.

Staff knew how to support people if they needed to in order for people to have a pain free and dignified death.

People, their families and staff were encouraged to be involved with the service. There were links with the local community schools and the local hospice.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of Registration Regulations 2009. You can see what action we told the provider to take at the back of the full version of this report.

Woodchurch House provides accommodation, nursing and/or personal care in purpose built premises. There was one person receiving accommodation and nursing/personal care when we inspected. It also provides a personal and /or nursing care service to people who hold tenancy agreements in their accommodation within Woodchurch House. Forty nine people were tenants and received personal and/or nursing care in leased accommodation suites. There were 50 people in total using the service during our inspection; of which 43 were receiving nursing care. The service is divided into two floors with the ground floor dedicated to nursing care and the first floor to people living with dementia; some of whom also require nursing care.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Woodchurch House was last inspected on 09, 10, 11 May 2017. Seven continuous breaches of legal requirements were found in relation to Regulation 9, 10, 12, 15, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and three other breaches were found in relation to Regulations 11, 13 and 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was placed into special measures.

After the inspection the provider sent us an action plan which detailed how they planned to address the breaches of Regulations, they regularly updated this to evidence what had been completed. The last update was received on 06 October 2017.

At this inspection we found that the provider and registered manager had made improvements to the service. However further improvements were needed in each of the five domains.

Risk assessments were not in place in relation to people’s medical needs. Some risk assessments needed further detail to protect people from the risks of harm.

Medicines had been well-managed and the computerised administration system supported staff to give and record medicines safely. The provider needed to make further improvement to the recording of topical creams and pain relief patches. We made a recommendation about this.

Effective systems were not in place to enable the provider to assess, monitor and improve the quality and safety of the service. Records were not always complete or accurate. The provider had made some improvements to systems. However, these had not been fully embedded, which meant further improvements were required.

All staff had not attended training relevant to people’s needs. Some staff had not received effective supervision.

People’s care plans had been reviewed and updated to ensure that their care and support needs were clear and their preferences were known. However, care plans did not all reflect each person’s current need or specific healthcare needs.

Complaints information was not in an accessible format to help people living with dementia understand.

The provider had made some improvements to the environment such as redecorating the ground floor. Further improvements were required such as redecorating upstairs and ensuring consistency of signage to aid people living with dementia to orientate.

Effective recruitment procedures were in place to check that potential staff employed were of good character and had the skills and experience needed to carry out their roles. Appropriate numbers of staff had been deployed to meet people’s needs. However, during one meal time when a person was agitated and upset there were not enough staff to ensure others were supported with their meals in a timely manner. We made a recommendation about this.

People were provided with meaningful activities to promote their wellbeing. People were able to access the secure grounds to gain fresh air and visit the pets. People accessed their local community both with their relatives and with the staff.

People had choices of food at each meal time. People were offered more food if they wanted it and people that did not want to eat what had been cooked were offered alternatives.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Deprivation of Liberty Safeguards (DoLS) applications had been made to the local authority. The registered manager was awaiting the outcome of these.

Staff knew and understood how to protect people from abuse and harm and keep them safe.

People were supported and helped to maintain their health and to access health services when they needed them.

Maintenance of the premises had been routinely undertaken and records about it were complete. Fire safety tests had been carried out and fire equipment safety-checked.

Staff were cheerful, kind and patient in their approach and had a good rapport with people. The atmosphere in the service was calm and relaxed. Staff mostly treated people with dignity and respect. However, some staff walked into people’s rooms/care suites without knocking. We made a recommendation about this.

People were supported to maintain their relationships with people who mattered to them. Relatives and visitors were welcomed at the service at any reasonable time and were complimentary about the care their family member’s received.

People and their relatives had opportunities to provide feedback about the service they received. Compliments had been received.

People and their relatives knew who to talk to if they were unhappy about the service. Complaints had been appropriately managed, investigated and responded to.

Relatives and staff told us that the service was well run. Staff were positive about the support they received from the management team. They felt they could raise concerns and they would be listened to.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

We found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

It is a requirement of this service’s registration with the Care Quality Commission, that there is a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The manager at Woodchurch House had become registered immediately prior to our inspection.

Woodchurch House was last inspected on 5 and 6 November 2016, following information of concern we received about the service. They were rated as inadequate overall at that inspection and placed into Special Measures. Prior to this they had been inspected in September 2016 when they were rated as requires improvement overall but inadequate for Safe, and January 2016 when they were rated as Inadequate overall.

At this inspection there had not been sufficient, sustained improvement and we continued to have concerns about the safety and well-being of some people, despite having made the issues clear in our previous reports. There had been inadequate management and provider oversight to ensure that risks were addressed and quality and safety made better.

Known risks to people such as from choking, from skin wounds, from dehydration, certain equipment or from being unable to use call bells had neither been properly assessed nor were actions to minimise the risks put into place. Staff were still not suitably deployed so that people received prompt and appropriate attention, and training and knowledge remained lacking in some areas. Most recruitment files had been improved but there remained an issue over unexplained gaps in employment history even though this had been specifically highlighted at past inspections.

Systems to protect people from abuse had not been operated effectively and incident reports had not been completed by staff when unexplained bruising, cuts and skin tears were noticed.

The principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty safeguards (DoLS) had not been consistently applied to ensure staff were always acting in people’s best interests or with their consent.

People’s dignity was not preserved if they became incontinent when there were delays in call bells being answered. Independence was not consistently promoted when people needed support to carry out exercises recommended by physiotherapy. End of life care records needed more work to include people’s personal preferences.

Complaints were recorded well but actions taken in response to them were not always robust or effective. Feedback was sought from people and relatives via surveys and meetings but again this was not always acted upon.

Care plans held person-centred information but this did not always match with other records and created the opportunity for error and confusion. Some records were neither accessible nor made available to us during the inspection. Auditing had been largely ineffective and was sometimes based on flawed data.

Medicines had been well-managed and the computerised administration system supported staff to give and record medicines safely.

Maintenance of the premises had been routinely undertaken and records about it were complete. Fire safety tests had been carried out and fire equipment safety-checked.

People and relatives told us staff were kind, considerate and caring and we observed staff treating people with gentleness and patience throughout the inspection. Records about people were stored securely and staff were mindful of people’s confidentiality and privacy.

There was a varied activities programme in place which had been improved to include many outings. People were seen to enjoy baking, games and musical entertainment and relatives commented on how much it meant to their loved ones to be involved socially.

Actions taken following our last inspection had not been sufficient to ensure people’s safety and well-being. We remained concerned that people were not consistently receiving appropriate standards of care. CQC is now considering the appropriate regulatory response to resolve the problems we found.

We found a number of breaches of Regulation.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

It is a requirement of this service’s registration with the Care Quality Commission, that there is a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run. There was no registered manager in place when we inspected and there had only been a registered manager for around a month during the last year. A new manager had started their induction into the service on 4 November 2016 and commenced work as the manager on 8 November 2016.

Woodchurch House was last inspected on 31 August and 1 and 2 September 2016.They were rated as requiring improvement overall but rated inadequate for safety. As the service had already been placed into special measures following an inspection in January 2016; (when it was rated as inadequate in every domain) it remained in special measures following the last inspection. We took enforcement action and asked the provider to submit an action plan to demonstrate how they would make the necessary improvements. The provider had assured the Commission that it had taken action to reduce risks to people which were identified at our previous inspection in August and September 2016. However, we found that risks to people had not been mitigated, and people had experienced harm and were at risk of continued harm. We took steps to mitigate harm to people which included alerting the local authority to the risk. The local authority and the clinical commissioning group, along with the CQC are supporting the service to make immediate improvements to ensure people’s health, safety and welfare.

On 4 November 2016 we received information of concern about Woodchurch House; which suggested that people living there might be at risk of harm. We responded to this by carrying out a focused inspection over the weekend of 5 and 6 November 2016.

As this was a focused inspection, we looked to see whether the service was safe, effective and well-led.

The service was not safe. Known risks to people had not been reduced; even though these had had been specifically highlighted in our last inspection report.

A medicine prescribed for heart problems had not been managed properly; creating a risk that people might be given it when they should not have it.

People had not been protected from abuse or neglect because staff did not always react promptly or appropriately to people’s calls for help. People’s private space and personal possessions were not protected by staff who allowed one person to enter rooms uninvited and take other people’s property away.

The service was not effective and there were not enough trained, experienced or competent staff deployed to meet people’s needs appropriately. Nurses that worked at the service had not had their competency assessed, and did not have the necessary skills or competence to support people safely or to recognise when people needed support.

Professional advice about people’s diet had not been followed and records about people’s intake were inadequately completed. This made it difficult to monitor people’s health and well-being. The management of people's urinary catheters did not include analysis of their fluid intake and output.

The leadership of the service was poor and this placed people at risk of harm. There had been a lack of provider and management oversight to ensure the safety and quality of the service.

CQC is now considering the appropriate regulatory response to resolve the problems we found.

It is a requirement of this service’s registration with the Care Quality Commission, that there is a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. There had not been a registered manager at Woodchurch House for almost a year at the time of our visit; however the manager had applied to become registered.

Woodchurch House was last inspected on 7, 8 and 11 January 2016.They were rated as inadequate overall at that inspection and placed into Special Measures. We took enforcement action and required the provider to make significant improvements in a number of areas by 15 March 2016. The provider sent us regular information and records about actions taken to make improvements following our inspection and the enforcement action.

At this inspection we found that improvements had been made in some areas. In others, however, the changes made had not addressed the issues; leaving some people exposed to risk of harm.

Assessments about individual risks had not always been followed through into practice; meaning that the risks to people had not been properly reduced. Medicines management had improved overall but there were still areas that needed attention to make them safe. Recruitment practices required further input to ensure that all staff employed were suitable for their roles.

Staffing numbers had increased following our last inspection, but the organisation of staff sometimes meant people’s needs were not met promptly. Training needs had been met for mandatory subjects, but staff would benefit from further instruction in some subjects. Supervisions had taken place and had resulted in actions being taken by the manager.

Some people’s needs in relation to eating and drinking were not consistently or properly managed. People enjoyed their meals and there was a good choice available. Healthcare had generally improved in areas such as wound care, but catheter management required attention. End of life care plans met National Institute of Clinical Excellence (NICE) guidelines.

The principles of the Mental Capacity Act (MCA) 2005 had been applied and people’s consent had been appropriately obtained.

Auditing carried out for the purpose of identifying shortfalls in the quality and safety of the service had been extended and was more in-depth, but needed reviewing to ensure it was wholly effective. Feedback about the service was sought from a variety of sources and had been acted upon.

Incidents and accidents had been properly documented and preventative actions were considered. Referrals were made promptly to the local authority safeguarding team when necessary and staff understood the importance of raising concerns so that they could be independently investigated. Statutory notifications required by the CQC had been submitted in a timely and appropriate way.

People’s safety had been protected through robust maintenance of the premises. Fire safety checks had been routinely undertaken and equipment had been serviced regularly.

People and their relatives gave mostly positive feedback about staff and we observed many kind and caring interactions. Some staff had however become desensitised to people who constantly called out for help. Activities had been developed and much improved so that people living with dementia could be involved and enjoy them.

Actions taken following our last inspection had not been sufficient to ensure people’s safety and well-being. We remained concerned that people were not consistently receiving appropriate standards of care.

At the last comprehensive inspection this provider was placed into special measures by CQC. This inspection found that there was not enough improvement to take the provider out of special measures and we found a number of breaches of Regulation.

CQC is now considering the appropriate regulatory response to resolve the problems we found.

The inspection was carried out by one Inspector over two hours. We carried out this inspection to follow up a compliance action in regards to the management of medicines, which we gave at our previous inspections in April 2014 and May 2014.

In April 2014 we found shortfalls in the medicines management. The manager informed us within two weeks that these shortfalls had been addressed and we returned to the home to inspect medicines management again in May 2014. We found that the items we had previously identified had been addressed, but found other aspects of medicines management which were unsatisfactory. The manager sent us an action plan stating that the medicines management would be fully up to date by 31 July 2014.

We carried out this follow-up visit on 22 August 2014, when we also inspected the management's ability to carry out suitable monitoring and assessments of the home. During this visit we inspected all four of the home's pharmacy rooms, and viewed documentation which included medicines' audits. We talked with the nurse on duty; with the duty manager on each floor, and with the clinical lead in the home. The manager was available in the home throughout this inspection.

We looked at the answers to five questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Is the service safe?

We found that the home had safe practices in place in regards to medicines management and administration. There were regular checks for medicines charts; and other auditing procedures were being carried out.

Is the service effective?

We saw that changes had been implemented in line with the home's action plan to meet regulatory requirements in regards to medicines. People received their medicines on time, from appropriately trained staff.

Auditing procedures had highlighted areas where improvements could be made in the home, and we found that relevant changes had been implemented and were working well.

Is the service caring?

People being admitted to the home had thorough assessments to review their care needs prior to admission. Some people wished to self-administer some of their medicines and they were supported to do this so long as they were assessed as able to manage their own medicines correctly.

The management obtained people's views of the home, and relatives' views, using customer satisfaction surveys every six months. We saw that the results of these were collated and used to bring about on-going improvements in the home.

Is the service responsive?

The manager had taken steps to ensure that staff responsible for administering medicines had attended further training in medicines administration; and would have a yearly assessment for their on-going competency.

We viewed the complaints file for 2014 and saw that the manager had investigated concerns and complaints where this was needed, and had responded to people appropriately.

Is the service well-led?

New auditing systems had been put in place in regards to medicines management. These included daily, weekly and monthly checks for different aspects of medicines administration.

We found that people's views had been obtained, and changes had been made as a result. This included a new sensory area for people with dementia; and more items on the walls for people with dementia to enjoy when walking along the corridors.

People said there had been noted improvements with food and activities. A relative had commented 'Overall it is a lovely, warm, bright and well run welcoming home. All the carers are very kind and caring and thoughtful, and provide love and attention to the residents.'

During this visit we visited all four of the home's pharmacy rooms; talked with the nurse on duty and the clinical lead in the home; and examined medication administration records (MAR charts) for two areas in the home.

We looked at the answers to five questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Is the service safe?

We found that medicines' management in the home was not safe.

We found that significant improvements had been made since our last visit. This included the implementation of correct storage for controlled drugs; correct storage for unused medicines waiting for disposal; hazard warning signs indicating where oxygen was stored; and handwritten entries on MAR charts signed and countersigned. We saw that drugs fridges and storage cupboards were now kept locked, and there were procedures in place for the management of the keys. Medication audits had been commenced.

However, we found there were other areas with regards to storage, administration and management of medicines that were unsatisfactory. This included many gaps in signatures on MAR charts for medicines on both floors. This meant that we could not confirm that people had been given their medicines correctly.

We found items of medication which were stored incorrectly; and one item in use which had gone out of date four days previously. Storage concerns included items in drugs fridges where they should not have been; and an item stored in a fridge which did not need to be stored in a fridge. External creams had been wrongly stored adjacent to internal medicines; both in storage cupboards, and in the medicine trolleys.

Is the service effective?

We found that medicines management was not effective.

We found a number of medicines which had been stored incorrectly. This included medicines which were stored at the wrong temperatures. (If medicines are not stored at the correct temperatures as identified on the pharmacy instructions, this could impair the effectiveness of the medicines).

We found one item of liquid medication which had gone out of date four days previously. This meant that the staff could not confirm that this medicine would be fully effective for the person concerned.

We found that there were many gaps in signatures for two files of MAR charts. This meant that the staff could not confirm if these medicines had been given to the people concerned.

Is the service caring?

We found that the service was not caring in respect of medicines' management.

We could not verify if people were being given their medicines at the correct times, or if doses were being missed, due to the many gaps in signatures on the MAR charts.

We found inhalers in use in two medicine trolleys which were unlabelled. This meant that staff could not confirm that the inhalers were being used for the correct people for whom the inhalers had been dispensed by the chemist.

Is the service responsive?

We found that concerns that we had highlighted at the previous inspection had all been dealt with. This included the fitting of correct storage cupboards for controlled drugs; locked storage for medicines waiting for disposal; hazard warning signs on doors where oxygen was stored; and two signatures for hand written entries on MAR charts.

This showed that the service was responsive in regards to carrying out changes in procedures when they knew this needed to be done.

Is the service well-led?

We found there was a lack of effective overall leadership in medicines management.

The clinical lead had commenced carrying out medication audits, and we saw that two of these had been completed. However, the audits had not picked up the concerns which we found at this visit. This showed that the auditing processes had not been properly assessed before they were implemented.

We found that the service had one nurse on duty during the day times for both floors. The nurse carried out nursing duties which included the administration of controlled drugs and giving injections; and being available for any assistance or advice needed in regards to other medicines. Most of the medicines were administered by duty managers, who were senior care staff. These staff had been given training in medicines' administration, and had been checked for their competency. However, our findings showed that the system was not working well, as there were so many errors found during our visit. We were unable to verify if this was due to inadequate staff training; insufficient numbers of nursing or senior staff; or general laxity in carrying out the required duties.

The inspection was carried out over six hours by one Inspector. We looked at the answers to five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Is the service safe?

We observed the care of people with dementia on the first floor during lunch time. We saw that the staff showed kindness and gentleness, and noticed when people were agitated or upset and needed additional support.

We inspected medication management and found that some aspects of medication storage and documentation were unsatisfactory. This meant that we did not find the service safe in regards to medicines management.

Is the service effective?

During the inspection we talked with people living in the home, and with staff and people's relatives. We viewed the premises and observed staff giving general care to people during the day. We read documentation which included some care plans, medication records, policies and procedures and staffing rotas. We found that these were generally well completed and demonstrated effective care for people.

We found that the home provided a suitable variety of food to meet people's nutritional needs and to provide them with sufficient choice.

We assessed the management of staffing levels, and found that the home had suitable numbers of staff on duty, except in occasional circumstances when the management had been unable to cover shortages due to staff sickness.

Is the service caring?

People that we spoke to said they were happy living in the home. Their comments included: 'I am so happy since I have lived here. The nursing care is excellent.' 'I love living here, I am very well looked after.' And 'I am very happy here. The food is good, and there are plenty of things to do. I played dominoes this morning!'

We found that people's preferences and interests had been recorded, and care and support was provided in accordance with people's wishes.

The home provided a wide variety of activities and entertainment for people to join in with as they wished.

Is the service responsive?

We found that the management was approachable and encouraged people to voice any concerns or ideas for change.

People were made aware of the complaints system, and had their comments and complaints listened to and acted on. However, we did not find that the complaints procedure was easily accessible.

Is the service well-led?

The service worked well with other services and health professionals to make sure that people received the care that they needed.

We found that auditing processes did not always identify areas of concern, so that these may not be picked up and dealt with in a timely manner.

People told us their privacy and dignity was always respected. People said their independence was encouraged and they were able to make choices in relation to their care and support.

People spoken with told us they were satisfied with the service they received and that care was personalised to their needs. One person said, 'It's very nice. I am happy here and there are a lot of people I can talk and chat to'. Another person said, 'I like the people here and they try and help'. People and/or relatives were aware of their care plan and involved in planning the care and support received.

People told us they had opportunities to express their views and give feedback about the service. A few people had the odd concern about an aspect of their overall service. These were discussed with the manager. The service had systems in place to assess and monitor the quality of the service people received.

People told us they received their medicines at the times they needed them, and in a safe way. People said their care and support needs were met and the majority of people spoken with felt there were sufficient staff on duty to enable this in a timely way.

People told us that their privacy and dignity was respected. People said they could make choices and decisions about their day to day lives. One person told us that staff "really look after me well".

People had consented to the care and support they received. They told us they were happy with the care and support they received and it was what they expected. People told us that the staff had the right skills and experience to meet their needs.

People we spoke with said they were happy with the way the service managed their medicines. However, we found that people's medication was not always handled safely. There was insufficient guidance in place for staff on the use of some medicines.

People benefited from a modern, spacious and homely environment that met their needs.

One person said, it was "home from home'. People felt there was sufficient staff on duty to meet their needs. However relatives and staff felt this was not always the case. Records were maintained and stored appropriately to promote people's confidentiality.