Woodthorpe Lodge

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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 developed a positive approach to learning within the service, which included the development of a culture based on openness and willingness to learn. People and relatives told us they knew how to raise concerns and felt confident appropriate action would be taken to address them.

The provider and management team had made improvements to how overarching themes and trends were reviewed and monitored. Records showed when accidents and incidents were reported by staff, action was taken to mitigate the risk of events taking place again. The registered manager and the provider demonstrated an open approach and told us about recent examples where lessons had been learned. For example, they had introduced a more detailed analysis and review of falls and incidents where people had experienced distress. This had resulted in review of people’s needs, staff training in dementia care, referrals to other agencies and purchasing equipment to mitigate the risk of further incidents. We saw there had been a reduction in incidents and accidents because of this approach, which meant people were more effectively protected from the risk of harm.

The provider had made improvements to how they 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. The provider had systems and processes in place to support admissions and transfers of care. They had reviewed pre-admission assessments to ensure these were sufficiently robust and captured the information needed to ensure people’s needs could be met by the service. Staff supported people and their families to identify safe transitions where people’s needs changed. Staff worked closely with health and social care partner agencies to ensure effective communication and people received timely care and treatment.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider had identified concerns had not always been shared quickly and appropriately prior to our inspection visit. They had implemented processes to address this and ensure all staff understood their roles and responsibilities in raising safeguarding concerns and following procedures. We saw recent potential safeguardings had been escalated in a timely manner. People told us they felt safe. Comments included, “I like being able to have a key for my room and I’ve a drawer with a lock too for my special things to stay safe. I don’t like the thought of just anyone being able to wander in” and “I’ve never felt unsafe here. Having the red button (call bell) is good too.” Staff demonstrated they understood their responsibilities in safeguarding people and received training and support to understand these. A staff member told us, “We have a clear understanding of what we need to do and what is expected of us. We can raise any concerns with the management team; they are listened to and acted on.”

The provider worked with people to understand and manage risks. However, we found risks around supporting people when they became distressed and risks associated with sexualised behaviours were not sufficiently assessed or mitigated. Where people presented this need, there was a lack of assessment and guidance in their care plans to ensure staff responded and intervened effectively and consistently. The provider reviewed and developed guidance and staff awareness following our inspection visit, though it was not possible to assess the impact of this on approaches and interventions. People and relatives felt staff worked well to keep people safe. One person told us, “I am an independent person. Staff know this and just remind me to use my walking frame following a fall. They help to keep me safe.” A relative described how staff reassured their family member during transitions using a hoist which distressed them. They felt staff handled this safely and with compassion.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. We observed a comprehensive system to ensure routine and specific safety checks were completed; however these were not routinely signed off by the management team as part of governance oversight. An emergency action plan was in place in case of events that required the service to be evacuated. This included scenario-based fire drills and personal evacuation plans, which provided staff with the knowledge and training to support people safely. People had a range of communal areas they could access throughout the day. The provider was in the process of reviewing these to ensure the environment and facilities fully met people’s needs and wishes.

The provider completed a monthly dependency tool to calculate the staffing required to meet peoples' care needs safely. This was updated with any changes in people’s needs and new admissions. Staffing rotas evidenced staff levels were generally maintained to the current dependency tool. However, some people expressed concerns around the deployment and availability of staff to meet people’s needs in a timely way. People’s comments included, “They seem short at busy times, like in the morning we get put into the dining room for breakfast but there’s no one to do it, unless a carer has time to make a drink and pop toast on. But they’re so busy, an extra server would help. I’d say there’s less staff around at weekends too somehow,” “They can be a bit short in the mornings and evenings rush when they’ve so many people to sort out. Weekends they seem a bit short too considering how quiet it is” and “I’d say they need a few more on the floors with all the hoisting that goes on.” Staff told us there were times when they felt staffing levels were not sufficient to meet people’s needs in a timely way. A staff member told us, “Morning times are a struggle if we only have 4 staff on. The senior is administering medicines, a staff member is supporting in communal area and doing breakfast and 2 staff are helping with personal care. There are a lot of people who require 2-1 help, and this means us having to apologise to people for them having to wait. This can lead to people being very unhappy.” A second staff member said, “There are times when staff are deployed to cover other roles, such as cleaning, and this means we are rushing around and not giving people the time they need.” We observed gaps in staff availability during breakfast time which meant staff who were involved in tasks such as medicines administration had to stop and support or seek assistance for people. We raised these concerns with the management team who told us they would review staff deployment throughout the day and consult with staff to make required improvements. Staff completed a range of training and particularly praised face to face training around dementia care. Although some staff had not received regular supervision, they told us they were able to regularly speak with their line manager who provided support and guidance. The provider followed safe recruitment procedures to ensure staff were safe and suitable to work in the service. This included checks with the Discloure and Barring Service (DBS) prior to staff commencing work.

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. The premises were clean, bright and airy and gave a fresh appearance. Housekeeping staff completed cleaning according to schedules to ensure all areas were maintained and good infection control was achieved. Staff used personal protective equipment (PPE) appropriate to the task they were completing. For example, gloves and aprons when supporting people with personal care.

Improvements were needed to ensure people’s medicines were always managed safely. We found body maps were not consistently completed for people who required transdermal medicines (patches applied directly to the skin). This is important to ensure safe application and rotation in line with national guidance. Protocols for people who required medicines to be administered in the event they became distressed were not always in place. These were needed to provide staff with robust guidance and ensure these medicines were administered correctly and appropriately. A person was prescribed pain relief medicine to be administered when required. However, records showed the person was receiving this on a daily basis. The management team referred this to their GP for review following our inspection visit. Staff responsible for administering medicines had received training and competency assessments. However, we observed staff were consistently disturbed during the administration process, despite wearing a do not disturb tabard. This increased the risk of potential areas as staff could not focus fully on the task. We raised these concerns with the management team who took remedial action to implement improvements. It was not possible to assess the impact of these at the time of this assessment. Other areas of medicine storage and processes were safe, and the provider demonstrated they strove to follow best practice. For example, emollient creams with a flammable risk were included in people’s evacuation and fire plans. People told us they felt well supported to take their medicines. One person said, “I have pills for blood pressure and a blood thinner. They’ve very strict and make sure I take it.”