Background to this inspection
Updated
20 March 2018
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.
The inspection took place on the 6 and 21 December 2017 and was unannounced. The inspection team on day one was made up of two inspectors and an expert by experience with experience of older people. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. Day two was completed by one inspector.
Prior to the inspection we reviewed all the information we held about the service including notifications. Statutory notifications are documents that the provider submits to the Care Quality Commission (CQC) to inform us of important events that happen in the service. The provider had completed a Provider Information Return (PIR). The PIR 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. We also contacted the Local Authority safeguarding and commissioning teams. We used all this information to plan the inspection.
During the two days of inspection we observed interaction between staff and people who used the service, looked around the communal areas and some people's bedrooms and spoke with two people who used the service and five visitors. We also spoke with the provider and registered manager, the deputy manager, a cook, activity worker, four members of care staff and a visiting health and social care professional. We reviewed care plans and documentation relating to the care for two people and reviewed their medicine administration records (MARs). We also looked at documents relating to the management of the service such as meeting minutes, quality assurance systems and servicing and maintenance records. In addition to this we received feedback via email from seven other health and social care professionals who shared their views with us about the care provided.
Updated
20 March 2018
This was an unannounced inspection which took place on the 6 and 21 December 2017. At the last inspection carried out in June 2015, the service was rated Good overall and Outstanding in the ‘Well led’ domain. At this inspection we found that the service was now Outstanding overall.
Woodleigh Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.
The service provides accommodation and personal care for a maximum of 34 older people, some of whom may be living with dementia. It is located in a quiet residential area in the town of Hessle, in the East Riding of Yorkshire. At the time of our inspection the service was fully occupied.
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.
During our inspection, we found exceptional standards of care. The registered manager and staff were absolutely committed to delivering a personalised service. They worked collaboratively with people, their visitors and health and social care professionals to ensure the care provided met each person's individual needs. We observed staff demonstrated a compassionate, kind and caring manner towards people who lived at the service. We saw many examples of how the caring approach of staff had a very positive impact on people's lives.
People received care and support that was extremely flexible and responsive to their individual needs and preferences. The registered manager and staff were creative in enabling people to live as full a life as possible, particularly where their skills had deteriorated. We saw numerous examples of staff going the extra mile, ensuring that the service was focused at all times on people living there. People's individuality was supported, which enabled people to grow in confidence and regain and develop as much independence as possible. The staff and management were very proud of the support they provided and the positive outcomes that people had achieved.
All the people, visitors and health and social care professionals we spoke with were extremely complimentary about the registered manager and staff at Woodleigh Manor. They were described with terms such as “Amazing”, “Excellent” and “Truly committed.” Visitors were very positive when talking about the staff team that supported their loved ones. One comment that had been left by a visitor said, ‘Staff are always there to help and advise, they always go the extra mile and give 100%.’
The registered manager and staff looked for creative ways to ensure people's needs were met, and ensured any obstacles were overcome when possible. People were consistently treated with dignity and respect and their privacy was respected. Staff were very kind, humorous and patient in their approach. People received care and support from a consistent and dedicated team of staff that put people first and were able to spend time with people in a meaningful way.
The service worked very well with other organisations. People, visitors, staff and health and social care professionals spoke highly of the registered manager; they told us they found them to be committed, supportive and approachable. One health and social care professional told us, "Woodleigh Manor has always gone above and beyond in what they have done for each of the service users I have supported there. This has been done in such a person centred way and I have always had great feedback from service users (if able) and families alike about the care that they and their loved ones felt they have received.”
Staff understood the provider's safeguarding procedures and could explain how they would protect people and who to contact if they had any concerns. Robust recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work.
Medicines were managed safely. Staff had received relevant training and regular medicine audits were taking place.
Care plans we looked at included personal information and were person-centred. The plans and associated risk assessments were reviewed and updated regularly or when anything changed.
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. However, during the first day of inspection we noted the provider had not always followed the correct process for making best interest decisions in line with the Mental Capacity Act 2005 (MCA). We saw some peoples bedroom doors were locked whilst they were in their rooms; this was not due to lack of staff as we judged there were sufficient numbers of suitably qualified, skilled and experienced staff to safely care for the number of people living at the service. The registered manager told us this was done to reduce the risk of other people using the service entering people’s private rooms and touching their possessions. They told us this had been decided in agreement with the person and their relatives where required. We were unable to see appropriate risk assessments completed in relation to peoples safety in the event of a fire, as capacity assessments and best interests decisions for those people who were unable to make this decision themselves had not been completed. The provider and registered manager responded promptly to these concerns and on the second day of inspection we saw appropriate action had been taken in line with the MCA and thorough assessments of the risk to people’s safety had been completed.
People had enough to eat and drink to maintain good health and nutrition. People had access to a range of support from health and social care professionals.
The registered manager took account of complaints and comments to improve the service. People and their visitors we spoke with told us they were aware of how to make a complaint and were confident they could express any concerns and these would be addressed.
The registered manager understood their responsibilities and ensured people, visitors and staff felt able to contribute to the development of the service.
Staff told us they really enjoyed working at the service and spoke positively about the culture and management. Staff were supported to be valued members of the service. We saw evidence of regular staff meetings and staff supervision sessions were undertaken regularly.
Further information is in the detailed findings below.