Woodlands Park Care Centre

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

We identified 2 breaches of the legal regulations relating to safeguarding people from abuse and a failure to notify the Care Quality Commission of certain events, in particular, when the local or funding authority had investigated potential abuse. We found people had been exposed to potential abuse by other people living at the home. These incidents had been recorded by staff but not all had not been reported to the local authority safeguarding team or the management team. Staff and leaders did not routinely and consistently follow the provider’s policies. For instance, where staff had been hit by people, they did not always complete an incident form. We found lessons were not always learnt from events or signs of distress to prevent a reoccurrence. However, people told us they felt safe, and this was supported by the views of relatives. The home was clean, and people were supported to receive their medicine as prescribed.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were not always supported by staff who fully understood what constituted an incident, which meant there were inconsistencies in practice. We received mixed feedback from relatives about communication about events affecting their family members. Some relatives told us the registered managers were proactive in contacting them, we were told the registered managers sent emails to relatives and informed them about any changes in their family member’s needs. However, some relatives told us they did not always get updates from the registered managers.

Staff and the registered manager told us about certain events which they would report to ensure learning was carried out to prevent a reoccurrence. Staff told us a daily meeting was used to share information about any falls or changes in people’s health. However, we found staff did not routinely report incidents as per the provider’s policy. The registered manager was aware of the duty of candour requirements, and we noted letters were written to affected parties offering an apology after certain events.

The provider had a number of policies to support staff understanding of how to promote a good learning culture. This included a Duty of Candour, Accidents, Incidents and Emergencies reporting. These policies were reviewed regularly. However, we found they were not routinely followed by the registered manager or staff. We found incidents recorded in the daily notes or in behavioural charts which had not been reported in accident records or referred to external bodies as required.

We received mixed feedback from relatives about how they were kept up to date with any changes in their family members’ needs. For example, one relative told us “They [staff] always contact me if there is any change in her health or manner, or if anything has changed”, however another relative told us “My only problem is the information sharing, for instance when the doctor visits. I really have to push to get full information”.

Staff and leaders told us systems were in place to ensure information was shared with external health and social care professionals. Care staff had access to essential information which staff ensured was provided when people were admitted to hospital.

We received positive feedback from healthcare professionals who visited the home regularly. They told us referrals to them were completed at the right time.

The provider and registered managers had systems in place to ensure information was shared with external professionals. We observed good communication between staff and visiting external professionals when we were at the home.

We were made aware of people being exposed to potenital abuse. There were incidents of people experiencing unwanted physical interventions and verbal abuse as a result of people's distress. However, people and their relatives told us they felt safe at the home.

Staff and leaders told us they had the confidence to raise safeguarding concerns. However, we found this was not always the case. Staff had reported physical interventions and altercations between residents on behavioural charts, however, they failed to always report this to the local authority safeguarding team for investigation.

People and staff had access to information about how to raise safeguarding concerns. However, some daily notes and other records contained entries demonstrating potential safeguarding concerns. We found the service did not always make safeguarding referrals to the local authority and action was not always taken to clarify the records with staff. We have asked the registered managers to review and make referrals where appropriate.

The provider had policies in place to support the reporting and recording of safeguarding concerns. However, we found these were not routinely followed. We found systems in place were not effective in monitoring safeguarding concerns.

People and their relatives told us they felt the service supported them to reduce the risk of harm. Many relatives commented on how their family member had benefited from the home environment. Relatives told us how the service had supported family members to have a reduction in medicines, which had had a positive impact on their wellbeing and safety.

Staff told us they were aware of risks posed to people, and how certain conditions or medicines increased the risk of harm.

Staff celebrated nutrition and hydration week. This provided an opportunity for people to experience different foods and drinks. However, people were at increased risk of harm due to lack of effective management of risk. People’s care plans stated they were at risk of dehydration and needed their fluid intake to be monitored. However, we found people’s fluid monitoring records did not always demonstrate what fluids and food people had been pffered or comsumed.

People were at a higher risk of dehydration due to poor record keeping. We found records were not routinely reflective of the support provided to people. For instance, we observed a morning and lunchtime on our first site visit, when we reviewed the records, for the same period, they did not reflect what we observed. People’s records showed they had been offered food and fluid when this was not the case.

Many of the relatives we spoke with commented on how the environment at Woodlands Park Care Centre was an improvement from where their family member had lived previously.

Staff and leaders told us the home was kept clean and had many features which supported people living with dementia.

People had access to a choice of seated areas. Consideration had been given to the décor of the home to meet the needs of people living with dementia. For instance, contrasting toilet seats, tactile objects on walls.

Processes were in place to monitor the environment. However, we found some improvements were required. The service had an electronic signing in book. When we asked for staff to show us who was in the building, the list available was not accurate. Only a selection of staff had access to another method of downloading the list. This meant in the event of an emergency, it would be unclear for staff to safely evacuate people. We asked the provider to ensure improvements were made without delay so staff could obtain accurate information on how many people were in the building. The provider confirmed action had been taken to ensure staff knew how to access accurate information about numbers of people in the building. The care home was supported by a competent member of staff who looked after the maintenance and safety of the building. Records relating to the required checks demonstrated compliance.

People and their relatives gave us mixed feedback about their views on staff numbers. Positive comments included, “I think the number is usually about right, they seem to be in full control”, “I think they have got it about right, there seems to be the right number of carers, I don’t see any difference in numbers at the weekends either” and “I would say that there were enough staff here.” However, others told us “There are never enough staff, I visit at weekends too and there are noticeably fewer staff then”, “Staff numbers do vary each shift really” and “They may be understaffed.”

Staff told us they felt staffing numbers during the day were manageable. However, we were informed nighttime staffing numbers were more difficult. The provider had made changes to nighttime staffing levels after our feedback. Staff told us they felt the training provided was suitable to their role.

We observed staff were task orientated in their daily duties. One member of staff showed us their list of jobs for the day, it included supporting people with their contience needs and meals. We observed staff demonstrated kindness and compassion towards people, for instance lowering themselves to the level of the person prior to talking. However, we also observed a lack of attention to people. For instance, one person was provided with a meal which was left on the table in front of them for over 30 minutes, a member of staff then attempted to support the person with the meal, however, it was cold. Another person was given a drink which they were unable to drink as the top of the cup had been incorrectly placed.

The registered manager advised us they assessed people’s level of dependency, and this was used to support the staffing levels. The night shift commenced at 19.00, 3 staff were on duty for the home until 07.00 the next morning. We reviewed records of support provided overnight. The records showed people were experiencing high levels of distress which needed a lot of staff intervention to reduce harm to them and other residents. We have asked the provider to review staffing levels at nighttime to ensure people and staff are protected from harm. We received feedback from the provider they had increased staffing levels following our discussion with them. The provider had robust and safe recruitment processes in place.

People and relatives did not have any negative comments about how clean the home was. All visitors had access to hand sanitiser.

Staff were aware of the need to good infection control procedures and were knowledgeable in what personal protective clothing/equipment was required.

The premises were clean and no malodours were noticed. The laundry was well-organised and in good order. Staff were seen observing good infection prevention and control practices, such as tying back long hair. Staff wore disposable aprons when they assisted people at mealtimes. Personal protective equipment was readily available to staff when needed for personal care.

Policies and procedures were in place for staff to follow regarding preventing infections within the home. The registered managers had undertaken monthly infection control audits. Where action had been identified this had either been carried out or was planned.

People and their relatives gave us positive feedback about how people’s medicines were managed. Relatives felt the staff were proactive with discussions with the GP to reduce any unnecessary medicines. We found evidence of medicines reviews carried out by the GP from the local GP practice. The care plans had the necessary information to support people with their health needs and prescribed medicines. Medicines were administered in a timely manner and recorded on the medicines administration record. The staff carried out medicine reconciliation effectively. Medicines reconciliation is the process of accurately listing a person’s current medicines.

Staff and managers understood the principle of medicines optimisation and said they helped people get medicine reviews. Staff said they were given induction and training and were competency assessed to handle medicines safely.

Medicines were given to people in a person-centred and caring way. Medicines were stored securely and safely. People were prescribed medicines for pain relief, rescue medicines for seizures, and medicines for constipation to be taken on a when required (PRN) basis. Guidance in the form of PRN protocols were in place to help staff give these medicines consistently. The medicines administration recording system was fit for purpose and stocks of prescribed medicines were managed appropriately. The staff recorded the date of opening for liquid medicines. There was a medicine policy in place and staff were aware of how to use it. The staff carried out regular medicine audits and they identified concerns related to medicines management and the actions that were taken to improve practice.