Woodlands Lodge

Updated 22 December 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.

This inspection took place on 29 November 2018 and was unannounced.

The inspection team consisted of one adult social care inspector and an ‘Expert by Experience’. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Prior to the inspection we reviewed the information we held in relation to Woodlands Lodge. This included the statutory notifications sent to us by the registered provider about incidents and events that had occurred at the service. A notification is information about important events which the service is required to send to us by law. We also contacted the Local Authority and the local Clinical Commissioning Group to get their opinions of the service.

We used all of this information to formulate a 'planning tool', this helped us to identify key areas we needed to focus on during the inspection.

During the inspection we spoke with the registered manager, six members of staff, activities co-ordinator, one member of kitchen staff, six people who lived at Woodlands Lodge and three visiting relatives.

We looked at the care files of four people receiving support, four staff recruitment files, policies and procedures, medicine administration processes, compliments and complaints, and other records relevant to the quality monitoring of the service.

We undertook general observations of the home over the course of the inspection, including the general environment, décor and furnishings, bedrooms and bathrooms of some of the people who lived at Woodlands Lodge, lounge and dining areas.

In addition, a Short Observational Framework for Inspection (SOFI) tool was used. SOFI tool provides a framework to enhance observations during the inspection; it is a way of observing the care and support which is provided and helps to capture the experiences of people who live at the home who could not express their experiences for themselves.

Updated 22 December 2018

This inspection took place on 29 November 2018 and was unannounced.

Woodlands Lodge is a residential ‘care home’ which provides accommodation and personal care for up to 40 older people, including people living with dementia. 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. Care is provided over two floors and each bedroom provided en-suite facilities. At the time of the inspection 27 people were living at Woodlands Lodge Care Home.

At the time of the inspection there was 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. During the inspection we found the registered manager to be open, transparent and receptive to the feedback provided.

This was the first inspection since the registered provider had registered with CQC in December 2017.

During this inspection, we reviewed the different quality assurance processes the registered provider had in place. Quality assurance processes helped to maintain the quality and safety of care people received however, they did not always identify improvements that were required in relation to people's care records.

We recommend that the registered provider reviews quality assurance processes to ensure care records contain the relevant amount of information required.

Staff were familiar with the support needs of the people they were caring for; although care records did not always contain a sufficient amount of person-centred information.

Medication management processes were safely in place. People received their medication by staff who were appropriately trained, regular audits were taking place and there was an up to date medication policy in place.

Recruitment was safely managed. People who were employed had undergone the necessary recruitment checks. Pre-employment and Disclosure and Barring System checks (DBS) were carried out and appropriate references were obtained for each candidate before they started working at the service.

Staffing levels were safely managed and people received safe and responsive care by staff who were familiar with their care needs.

Risk assessments were in place for people who lived at Woodlands Lodge. People’s level of risk was assessed and established from the outset, support measures were in place to mitigate risks and assessments were regularly reviewed and updated.

Staff told us that they received up to date information in relation to people’s health and well-being needs on a daily basis.

People were protected from harm and abuse. Staff were familiar with safeguarding and whistleblowing procedures, they told us how they would raise their concerns and the importance of complying with safeguarding and whistleblowing policies and procedures as a measure of keeping people safe.

There was an accident and incident reporting policy in place. Accidents and incidents were routinely recorded, they were appropriately managed and the registered manager established trends to identify if risks needed to be further mitigated.

The home was clean, hygienic and odour free. All areas of the home were well maintained and people lived in a safe, calm and homely environment.

Infection prevention control measures were in place and staff had access to personnel protective equipment (PPE) such as gloves, aprons and sanitizing gels.

Weekly, monthly and annual health and safety audits and checks were completed to help monitor and assess the quality and safety of the home. Regulatory compliance checks were also completed; compliance certificates for gas, electricity and legionella were in place during the inspection.

The registered provider was complying with the principles of the Mental Capacity Act, (MCA) 2005. Consent to care and treatment was gained in line with the MCA. People’s capacity was assessed from the outset and records contained the relevant information in relation to the persons capacity. Appropriate Deprivation of Liberty Safeguards (DoLS) were submitted to the local authority and records contained relevant ‘best interest’ information and restrictions which were in place.

Staff received regular supervision and were supported with training, learning and development opportunities. Staff received a variety of different training opportunities which enabled them to provide the safest and most effective level of care.

People’s nutrition and hydration support needs were effectively assessed, monitored and managed. Staff completed appropriate clinical tools to help identify any risks. Referrals to external professionals were taking place and care records contained appropriate advice and guidance that needed to be followed.

We received positive feedback about the quality and standard of food people were offered. Meals were well presented, people received a choice of food and were encouraged to share their suggestions and preferences in relation to the menus that were prepared.

People were treated with dignity and respect. Staff provided kind, caring and compassionate support. People’s independence was promoted and we received positive feedback about the quality and safety of care people received.

Confidential information was securely stored and protected in line with General Data Protection Regulation (GDPR).

There was a complaints policy in place. People and relatives were familiar with the complaints process and told us they would feel comfortable making a complaint if required. Complaints were appropriately managed; at the time of the inspection there was no ongoing complaints.

People were encouraged to participate in a range of different activities. We received positive feedback about the different activities that were taking place. Activities were fun, stimulating and helped to keep people motivated and engaged.

Systems were in place to gather feedback regarding the provision of care people received. People, staff and relatives were encouraged to share their views, opinions and thoughts around the quality and safety of care.

The registered manager was aware of their regulatory responsibilities. The registered manager notified CQC of all events and incidents that occurred in the home in accordance with statutory requirements.