We carried out a review of the data available to us about Woodthorpe Lodge on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Woodthorpe Lodge, you can give feedback on this service.
Woodthorpe Lodge is a care home registered to provide personal care for up to eight people who may have a learning disability or a mental health condition. There were five people living in the home at the time of our inspection. However, one person was on home leave.
Woodthorpe Lodge is purpose built and the accommodation is all on the ground floor. The service applied the principles and values of registering the right support, right care and right culture and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.
People’s experience of using this service and what we found
There was a lack of clear guidance for when ‘as needed’ medicines would be needed. The provider had recognised these risks in a recent audit and promptly improved the guidance and sent evidence of this . Medicines were safely managed.
People felt safe at the service. Staff knew how to recognise potential abuse and where to report their concerns. They felt confident in the management team to act on any concerns.
People’s care needs were recorded in care plans. This allowed clear guidance for staff to follow to keep people safe. The environment was safe and environmental checks (for example, for fire safety) were regularly made.
There were enough staff to keep people safe. People who required one to one staff support, had this arranged. Staff received suitable training for their roles. Staff spoke highly of the quality of this training.
The inspection was completed during the COVID-19 pandemic. The manager was aware of current government guidance and ensured the service followed this guidance. This included regular cleaning, correct use of personal protective equipment and testing of residents and staff.
Any incidents that occurred at the service were recorded. The management team reviewed these records to ensure lessons were learnt and improvements made if needed.
The service was well led. The previous inspection was rated inadequate, but the management team had created an action plan to undertake the required improvements. This meant the service was no longer in breach of regulation. Staff spoke highly of the management team, and the positive culture it had created.
The management team had worked to improve the service. At the last inspection, there were concerns about a poor culture. The culture was now positive and person centred. This promoted good outcomes for people.
There was good engagement with stakeholders and professionals. There was ongoing work to ensure the service continued to improve.
We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.
This service was able to demonstrate how they were meeting and underpinning principles of Right support, right care, right culture. The service encouraged people’s choice, control and independence. There was a positive ethos and care was person centred
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection (and update)
The last rating for this service was inadequate (published 7 October 2020).
There were multiple breaches of regulation. We added conditions to the providers registration, requiring them to create and send regular action plans. The provider completed these action plans. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
At the last inspection, this service was put in Special Measures. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
Why we inspected
This was a planned inspection based on the previous rating.
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.
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.
Woodthorpe Lodge is a care home registered to provide personal care for up to eight people who may have a learning disability or a mental health condition. There were seven people living in the home at the time of our inspection. However, one person was on extended home leave.
Woodthorpe Lodge is purpose built and the accommodation is all on the ground floor. The service did not fully apply the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.
People's experience of using this service and what we found
People were not always protected from the risk of avoidable harm or abuse because the systems and processes in place to safeguard people were not effective. The provider’s incident management policies and procedures were not routinely followed. Opportunities to learn from incidents were missed. There was a closed culture where staff were reluctant to use the provider’s whistle blowing procedure.
Risks associated with people’s individual needs lacked detailed guidance for staff to effectively manage and reduce risks. Support plans and risk assessments had not been reviewed at the frequency the provider expected.
Staff lacked specific training in some areas and refresher training had not been kept up to date. The environment had not always effectively met people’s needs and ensured their safety. Staff had not received opportunities to discuss their work, development and training needs.
There was not a registered manager. There was a delay in the covering management team having access to key documents to effectively monitor the service and review incidents that had occurred.
The provider’s initial response to concerns raised about increased risk, closed culture and governance was limited. However, following our inspection the provider took immediate action and made improvements to our greatest concerns about safety.
Infection prevention and control procedures reflected Covid-19 pandemic. However, individual support plans and risk assessments in relation to Covid-19 had not been completed. This meant people were put at increased risk during the Covid-19 pandemic.
Staff deployment was based on the numbers of people living at the service and not their individual assessed needs. It was unclear how people’s additional care and support needs were being met.
Medicines prescribed to be administered when required, had protocols but lacked specific guidance for staff. Medicine reviews and oversight and management was ineffective due to poor record keeping and follow up.
Staff morale was low, and the staff team did not feel valued and involved in the development of the service.
Systems and processes to assess and monitor quality including health and safety had not been kept up to date.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was Good (Published 17 January 2019). The rating for the service has changed from Good to Inadequate. This is based on the findings at this inspection.
Before our inspection we received concerns in relation to their being a closed culture, financial and verbal abuse from staff, poor management of incidents and governance. We raised these concerns pre-inspection with the provider but were not sufficiently assured. 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.
Why we inspected
The inspection was prompted due to concerns received about failure to protect people from avoidable harm or abuse, staff culture and governance. A decision was made for us to inspect and examine those risks.
We have found evidence that the provider needs to make improvements. Please see the safe, and well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this report.
Enforcement
We have identified breaches in relation to safe care and treatment, safeguarding service users from abuse and improper treatment and good governance.
Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the 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.
The service was registered to provide support for up to eight people who may have a learning disability or mental health condition. There were seven people living in the home at the time of our inspection.
Woodthorpe Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.
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.
People continued to receive safe care and there were enough staff to provide support to people to meet their needs. Staff had been suitably recruited to ensure they could work with people who used the service. People were protected from the risk of harm and received their prescribed medicines safely and were helped to take responsibility for their medicines.
The care that people received continued to be effective. People made decisions about how they wanted to be supported and they could decide what to do and how to spend their time. Where people lacked capacity, they were helped to make decisions. Where their liberty was restricted, this had been identified and action taken to ensure this was lawful. People were responsible for shopping and cooking the food they wanted to eat and supported to develop independent living skills. They received support to stay well and had access to health care services. Staff had training and professional development that they required to work effectively in their roles.
The care people received remained good. People had developed positive relationships with the staff, who treated them with respect and kindness. Staff helped people to make choices about their care and their views were respected. People were involved in the planning and review of their care and family members continued to play an important role. Where people had any concerns, they could make a complaint and this was responded to.
The service continued to be responsive. People could participate in activities that interested them and be independent. Care records were personalised and contained relevant information for staff to help them provide the care people required. Information about making a complaint was available for people and they knew how to complain if they needed to.
The service continued to be well-led. Systems were in place to assess and monitor the quality of the service. People and staff were encouraged to raise any views about the service on how improvements could be made.
Woodthorpe Lodge is registered to provide accommodation and personal care for up to eight adults with mental health needs. Seven people were living there at the time of our inspection.
The service did not have a registered manager at the time of our inspection visit. 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 Woodthorpe Lodge was in the process of applying to become the registered manager.
People were protected from the risk of abuse and avoidable harm. Risks associated with care were identified and assessed. Staff had clear guidance about how to meet people’s individual needs. Care plans were regularly reviewed with people and updated to meet their changing needs and preferences.
People were happy, comfortable and relaxed with staff. They were cared for by sufficient numbers of staff who were suitably skilled, experienced and knowledgeable about people’s needs.
The provider took steps to check potential staff were suitable to work with people needing care. Staff received one-to-one supervision and had regular checks on their knowledge and skills. They also received regular training in a range of skills the provider felt necessary to meet the needs of people at the service.
The systems for managing medicines were safe, and staff worked in cooperation with health and social care professionals to ensure that people received appropriate healthcare and treatment in a timely manner.
Appropriate arrangements were in place to assess whether people were able to consent to their care. The provider was meeting the legal requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DOLS). This meant people’s rights were being upheld, and any restrictions in their care were lawful and proportionate.
People were supported to be involved in their care planning and delivery. The support people received was tailored to meet their individual needs, wishes and aspirations.
People understood how to make complaints or raise concerns. The provider had an accessible complaints policy and procedure.
Systems were in place to monitor the quality of the service provided and ensure people received safe and effective care. These included seeking and responding to feedback from people in relation to the standard of care. Regular checks were undertaken on all aspects of care provision and actions were taken to improve people’s experience of care.
This unannounced inspection was carried out on the 11June 2015.
Woodthorpe Lodge provides accommodation and personal care for up to seven people with mental health problems. At the time of the inspection there were seven people living in the home.
The service did not have a registered manager in post. 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. A manager had been appointed and they were in the process of registering with CQC.
People were not always protected from avoidable risks. Risk assessments had not always completed. In some cases where there was a risk assessment it was not always followed. However, staff were aware of their duty of care to keep people safe and staff were trained to recognise and respond to signs of abuse. Information on whistleblowing was available to staff and they knew how to use it.
Medication was administered, recorded and managed appropriately.
The staff had appropriate training, supervision and support, and they understood their roles in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).
People had their nutritional needs supported. There was a variety of food available and people were included in shopping and menu planning.
People were supported to access health and social care professionals on a regular basis. People were supported to pursue their hobbies and to continue their relationships with their family members and friends.
Where possible people were involved in the decisions about their care and their care plans provided information on how to assist and support them in meeting their needs. The care plans were reviewed and updated regularly.
Staff were knowledgeable about the people needs and were caring, kind and compassionate in their interactions. People were cared for in a manner that promoted their privacy and dignity. People felt listened to and had their views and choices respected.
The service was managed in an inclusive manner that invited people, their relatives and staff.to have an input to how the home was run and managed.
The service had systems in place to assess, review and evaluate the quality of service provision. The majority of these were effective but they had not recognised the issues we identified in the management of risk.
Is the service safe?
People told us they felt safe and had no concerns regarding the staff that supported them. We saw the provider had appropriate procedures in place to report any allegations of abuse and staff had received training in recognising potential abuse and who to report any concerns to.
The service was clear about their responsibilities under the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Where people lacked capacity and decisions needed to be made in their best interests, the provider had acted in accordance with legal requirements.
Is the service effective?
We saw people's health and care needs were assessed and up to date support plans were in place. People we spoke with told us they were satisfied with the service and thought they had the right support. One person said “It’s good here” and another told us they thought they had improved and felt better since using the service. They told us “I love this home”. However, two people thought some people were treated more favourably than others, which had the potential to create a negative impact for them.
External health and social care professionals told us they thought the service managed people’s needs well and one described it as absolutely excellent.
Is the service caring?
People told us they were supported by friendly staff.
Our observations showed that staff demonstrated a caring approach towards people. Staff interactions with people were positive and an external professional told us “Staff are very understanding, communication is very good”.
Relatives we spoke with were generally satisfied with the service but two told us they were not kept informed on a regular basis of any issues affecting their family member.
Is the service responsive?
Staff had received training in all essential areas, including the MCA and the DoLS and safeguarding people from abuse. External health professionals we spoke with confirmed that staff were knowledgeable about people’s individual needs. One said “I’ve been really impressed with how they’ve managed” and described the staff team as empathetic.
Is the service well-led?
We found the provider had effective systems in place to monitor the quality of the service, and to identify and manage risks to people using the service, including monthly reports on learning form any incidents, regular meetings with staff, reviews of the support people using the service received and a clear complaints procedure. Records we saw confirmed that audits were up to date.
People we spoke with told us they were able to make comments to staff and the manager and that they were listened to, although one person said they did not think any action was taken when they raised issues.
We saw reports from external commissioners that told us the service was operating safely.