Woody Point

Updated 23 August 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 4 inspectors.

Service and service type

Woody Point is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us.

Woody Point is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We carried out two site visits to the service on 24 April 2023 and 20 July 2023. We spoke with 4 people who lived at the service. Not everyone was able to tell us about their experience of receiving care so we observed staff interacting and supporting people.

We spoke with 4 staff, the registered manager and the provider's nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spoke with a representative from the provider and a manager from another of the provider's services.

We reviewed 3 people’s care records which included their support plans, risk assessments and medicine records. We reviewed 3 staff recruitment records and other documents related to the running of the service which included staff rotas, training information, audits, surveys, meetings, and quality assurance records.

After the site visits we received further documentation electronically, requested from the registered manager relating to the management of the service and environment. We spoke with a relative, and the local authority contracts team. We received electronic feedback from two members of staff and 2 health and social care professionals.

Inspection activity ended when we gave feedback on 2 August 2023 to the registered manager and a representative from the provider.

Updated 23 August 2023

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

About the service

Woody Point is a residential care home providing personal care to up to 6 people. The service provides support to adults with learning disabilities, autism, and mental and physical healthcare needs. At the time of our inspection there were 6 people using the service.

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

The service was not able to fully demonstrate how they were meeting the underpinning principles of right support, right care, right culture, and best practice guidance. This meant people were at risk of not receiving the care and support that promoted their wellbeing and protected them from harm.

Right Support:

People were not always cared for and supported in a secure, clean, well-equipped, well-furnished, and well-maintained environment that met their sensory and physical needs. We identified concerns that had not been fully risk assessed and mitigated against which put people at risk of harm.

There were enough staff to meet people’s needs. Staffing challenges including personnel changes, retention and recruitment had impacted on continuity of care and there were instances of people’s routines being affected. To maintain safe staffing levels the registered manager had been covering care shifts instead of overseeing the service. The provider was taking action to address this through active recruitment and had recently employed two members of staff and had plans for further senior level support.

Overall 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; but there were inconsistencies in the policies and systems in the service to support this practice. Although the outcomes for people were appropriate the management team were not always confident in reflecting shared decision making and documenting best interest decisions. We signposted the registered manager to access support in this area.

Right Care:

There was a calm and relaxed atmosphere in the service. Staff were respectful and supportive in their interactions with people. Where people required support with personal care this was provided in a discreet way and promoted people's dignity and privacy.

Right Culture:

The provider's governance arrangements did not provide assurance the service was well led. Systems and processes to oversee the safety and quality of the service were not robust and effective. They had not identified the shortfalls we found during our inspection and regulatory requirements were not always being met.

The registered manager’s responsibilities were too great and this had impacted on their oversight of the service. In addition to covering care shifts at Woody Point they supported the provider’s other managers nearby, who were new to the role. The provider’s representative were not based locally in the area and acknowledged that a more visible presence was needed to support the registered manager and had plans to address this.

The registered manager and provider’s representative were open and honest about the shortfalls at the service. They engaged with the inspection positively and demonstrated a commitment to making any necessary improvements.

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 15 March 2019).

Why we inspected

We received concerns in relation to the care people were receiving. As a result, we undertook a focused inspection to review the key questions of safe, effective, and well-led only.

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 has changed from Good to Requires Improvement based on the findings of this inspection. You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement and Recommendations

We have identified breaches in relation to Regulation 12 that ensures people have safe care and treatment at all times and Regulation 17 relating to governance arrangements in the service.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress.

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