Archived: Woodham House Daneswood

Updated 8 November 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 14 and 29 August 2018. The first day of the inspection was unannounced and the second day was announced. The inspection team included an inspector and one 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.

Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that is completed by the provider to give some key information about the service, including what the service does well and what improvements are required. We also viewed the information we held about the service, including statutory notifications received. A notification is information about important events which the service is required to send us by law.

We also completed general observations of the service, communal areas and the interactions between staff and people. We spoke with two people using the service. We spoke with the registered manager, project coordinator and two members of staff.

During the inspection we looked at three care records, four staff recruitment files, staff rotas, training records, and medicines records for all the people living at the service. We also looked at other records relating to the management and maintenance of Woodham House Daneswood.

After the inspection we requested and received feedback from two health and social care professionals.

Updated 8 November 2018

This unannounced inspection took place on 14 and 29 August 2018. Woodham House Daneswood can accommodate up to 15 people. The service is situated in a purpose built large building with communal areas. People had their own bedrooms with en-suite facilities. Woodham House Daneswood 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. At the time of this inspection eight people with a mental health condition lived at the service.

At the last inspection on 20 and 24 July 2017, we found that the service did not meet the fundamental standards. We found four breaches of regulations relating to the management of risks to people's health and welfare, fit and proper persons employed, person-centred care and good governance. We also made four recommendations about seeking and acting on people's views about their nutrition, access to areas of the home, managing complaints and person-centred planning. We requested the registered manager send us an action plan to tell us how they planned to make improvements to the service.

At this inspection we followed up on the breaches of regulations to see if the registered provider had made improvements as required. The registered manager had taken action to address some of our concerns from our previous inspection. We found action had been taken on meeting people's nutritional needs and managing complaints. But, we found continued breaches in person centred care, safe care and treatment and good governance. We found a new breach in staffing. We made one recommendation about seeking current guidance and best practice on infection control.

The service has 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.

Medicines for people were not always managed safely. People had their prescribed medicines. Staff had their competency assessed to ensure they were safe to administer medicines for people. There were systems in place for checking room temperatures, storage, ordering and disposal of medicines. However, we found medicine administration records were not always completed accurately.

There were not enough staff working at the service. Records also showed that the provider’s recommended numbers of staff were not always on duty to provide people with safe care and support.

Pre-employment checks were not completed thoroughly to ensure the suitability of the staff working at the service. We found one member of staff provided inconsistent documents relating to their previous employment, identification and permission for the right to work in the UK. These concerns were shared with the registered manager.

There were systems in place to monitor and review the service. Audits of the service occurred on a regular basis. However, the audits did not find the concerns we found with some aspects of the service.

Care records did not contain end of life decisions. People did not discuss how they wanted the care and support delivered at that time. Staff had not completed end of life training or had developed knowledge of palliative care. But no one living in the service was receiving end of life care during the inspection.

People had some activities arranged for them. Staff supported people outside the service with attending activities they enjoyed. However, staff did not offer therapeutic activities that people could benefit from being involved in their home. The therapeutic area was locked during our visit so people did not have access to this area of their home.

The registered provider had a safeguarding policy. Staff followed this policy and process to protect people from harm and abuse. Staff managed allegations of abuse and reported them to the local authority for investigation.

Staff identified risks to people’s health and wellbeing. Risk management plans were developed to manage and mitigate those identified risks for people.

Staff were supported with an induction programme, training, supervision and an appraisal. Staff records held copies of meetings staff had.

Staff understood the Mental Capacity Act 2005 (MCA) and protected people’s rights. People gave staff their consent to receive care and support. Care documents were signed and agreed to by people or their relatives.

People had enough to eat and drink throughout the day. Meals were cooked on site by staff and some people cooked meals for themselves with the staff support. The menu was flexible enough to meet people’s individual preferences and nutritional needs.

Staff attended to people’s health care needs. People had access to health care services when their needs changes. People attended regular health care appointments and annual health care checks.

People said staff were kind and respectful to them. Our observations showed that staff had promoted people’s dignity. The service had communal areas where people had the privacy they needed if they wanted some time alone or if they had visitors.

Assessments were completed with people and their relatives. Health and social care professionals were involved in their assessment of needs. These determined whether staff could manage people’s needs appropriately.

There were systems in place for people to make a complaint about the service. People said they could discuss their concerns with a member of staff if they needed.

The registered manager understood their responsibilities in relation to their registration with the Care Quality Commission (CQC). The registered manager kept CQC informed of events that occurred at the service.

Staff enjoyed working at service. Staff said the registered manager was supportive and listened to their views.

Staff developed relationships with voluntary, health and social care services, this helped people to receive appropriate and co-ordinated care.

You can see what actions we took at the back of the full version of this report.