Archived: Woodcot Lodge Care Home

Updated 25 November 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on the 21 & 22 September 2016 and was unannounced. The inspection team over the two days consisted of three inspectors, one inspection manager and a specialist advisor who had knowledge in the care of older people, dementia care, neurological conditions, tissue viability and palliative care.

Before the inspection, we reviewed previous inspection reports, action plans from the provider, and safeguarding notifications. A notification is information about important events which the provider is required to tell us about by law. Before the inspection, the provider completed a Provider Information Return. This is a form that asks the provider to give some key information about the service, what the service does well, and improvements they plan to make.

During the inspection we spent time talking to the registered manager, two regional managers, 14 people, four relatives, and 12 members of staff. We looked at minutes of staff meetings, residents meetings, policies and procedures, monthly reports by the provider’s regional manager and the complaints log. We looked at six staff recruitment files, training and supervision records and the care records of 10 people.

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 observed interactions between people and staff.

Updated 25 November 2016

We carried out this comprehensive inspection on 21 & 22 September 2016. This inspection followed two comprehensive inspections in 2015 and a focussed inspection carried out in April 2016. The last two comprehensive inspections were carried out in March 2015 and September/October 2015 which had led us to follow our enforcement pathway. The focussed inspection was carried out to help guide us in terms of our enforcement pathway. Since these inspections we have continued to be notified by the provider of significant events and concerns which they have reported to the local safeguarding authority. We also received information from external sources. We had received action plans from the provider informing us of the action they were taking to make improvements and achieve compliance with all the Regulations of the Health and Social Care Act 2008.

Woodcot Lodge is a nursing home which is registered to offer personal and nursing care to 85 older people, some of whom live with dementia. The home had three floors, with a lift providing access to all floors. Since the focused inspection in April 2016 the provider had made the decision to close the second floor. Some people from this floor were moved to the other two floors of the home and some people were relocated in other homes. The ground floor was referred to as 'residential' and the first floor accommodated people who had a nursing need. At the time of our inspection 54 people lived at the home; three of these people were in hospital.

The home 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.

There had been a history of non–compliance with the regulations at this service since September 2013, which we had continued to monitor. Due to the on-going breaches we had been following our enforcement pathway. At the focussed inspection in April 2016 we found the provider was still in breach of three regulations, which related to risk assessments, personalised care and quality assurance systems. Whilst these breaches remained we found the impact on people was low.

At this inspection we found progress had been made in all areas and the service was no longer in breach of regulations regarding safe care and treatment, person centred care and quality assurance. However one recommendation has been made and there is a continued breach of Regulation 17 regarding record keeping.

Staff understood the principle of keeping people safe and the registered manager made appropriate referrals to the local safeguarding team. Risk assessments had been completed and staff were aware of the risks facing people and how to minimise these risks. Staffing levels met the needs of people during the inspection. When staffing levels were low at short notice the registered manager was unable to fill these shortages, which meant staff were rushed.

Recruitment checks had been completed before staff started work and updated for long term staff to ensure the safety of people.

Medicines were administered and stored safely; however there had been a few recent medicine errors, which had been investigated and reported, but the errors were similar to concerns in previous inspections, We have made a recommendation regarding the policy and processes in place for when medicines have been refused by a person for a period of time.

There was a training programme and staff enjoyed the training and felt it equipped them to do their job. Staff had a good knowledge of the Mental Capacity Act (2005) which had been incorporated into people’s records. People enjoyed their meals and there was support for those who needed it. People were supported to access a range of health professionals.

People received personalised care which took into account their choices and preferences. People felt confident they could make a complaint and it would be responded to. Complaints were logged and there were recordings of investigations into complaints.

People felt the staff were caring, kind and compassionate. The home had an open culture where staff felt if they raised concerns they would be listened to. Staff felt supported by the registered manager and were clear about their roles and the values of the home. Records were not always accurately maintained. There was an effective quality audit system.

We found a repeated breach in one of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

With regard to previously identified concerns, we have followed our enforcement pathway which resulted in us taking proposed action to cancel the providers registration for this service. The provider made representations to us against this decision but it was not upheld, which resulted in the decision being scheduled to be heard at a first tier tribunal at a future date. However, as a result of the findings of this inspection, we have found the provider has taken appropriate action and has made improvements which we will continue to review through monitoring and inspection.