Archived: Woodtown House

Woodtown House is a nursing home in one adapted building providing personal and nursing care to 19 people with mental health difficulties at the time of the inspection. The service can support up to 22 people.

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

There were not enough staff to meet people’s needs. In the two weeks prior to the inspection and including 17 June 2021 staff rotas showed staffing levels fell below the planned levels on six occasions during the day, on four occasions this was for full shifts and on two occasions this was for partial shifts. As a result, staff in other roles had to provide cover to ensure the safety of the service. This had an impact on people’s ability to engage in meaningful occupations to aid their recovery, rehabilitation and physical and mental health well-being. People commented: “We sometimes cannot go out due to staffing levels.” and “There are not enough staff here to see to everybody’s needs. There is a lack of staff to do activities. The staffing ratios are not right. It is so frustrating.”

Staff morale was low due to them feeling unable to provide people with therapeutic and holistic opportunities. Staff felt unable to adopt the home’s ethos of recovery and rehabilitation. Staff were not supported through adequate supervision with constructive feedback on their performance.

Staffing issues impacted on the ability of the service to manage risk. Staff raised concerns about accessing key care and risk assessment documentation due to poor internet access at the home. Concerns were also raised in relation to agency staff access to key documents due to the IT issues which meant they did not have access to a summary of people’s care and support needs which they could refer to quickly. This, impacted on staff ability to provide people with safe care and support in line with their specific needs. A staff member commented: “Risk assessments are on the care plans, but they are online, so if the internet is down you cannot see them.”

Following our inspection, we asked several times from 22 June 2021, for information relating to care plans, risk assessments and progress notes from the home. We received this information on 7 July 2021. We were informed that issues with internet access meant, there had been difficulties sending the requested information. This time lag demonstrated that staff access to key information was compromised impacting on their ability to proactively support people in line with their individual needs in a safe way. The provider was aware of the need to improve internet access at the service, with actions being taken but currently unsuccessfully.

We were not assured that the provider was promoting safety through the layout and hygiene practices of the premises. They had not identified where damage to the fabric of the building made it difficult to clean effectively.

The service was unsafe and was not well-led as shown by two breaches of regulation linked to good governance, and staffing.

The provider had not fully recognised the quality of the service had significantly deteriorated. Systems in place to monitor and review the quality of care and ensure the service was meeting people's needs safely were not adequate. This therefore put people at risk of unsafe care.

People said the service was not always well-led. There was a poor culture that did not engage with people, and staff, to deliver a person-centred, open, inclusive and empowering service. Staff said they felt the provider did not value them or their work, which was having a negative impact on their own physical and mental health well-being. The provider’s statement of purpose aims, and objectives were not being followed.

There was no registered manager in post. A new manager had started on 3 June 2021 and was due to apply to register with the Care Quality Commission.

There were systems in place to safely monitor medicines from the point of ordering to administration.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good (published 21 January 2020).

Why we inspected

We undertook this targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about staffing levels being inadequate to safely meet people’s care and support needs and the overall lack of governance of the service by the provider. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with staffing and governance arrangements, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

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.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well-led sections of this full report.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Good to Inadequate. This is based on the findings at 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 Woodtown House on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment, staffing and good governance.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe, and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We found the following examples of good practice:

The staff were following up to date infection prevention and control guidance to help people to stay safe. The registered manager ensured staff understood why every measure was in place.

The provider provided training to ensure staff knew how to keep people safe during the COVID-19 pandemic.

Staff supported people to occupy themselves whilst maintaining their safety. A marquee has been set up in the grounds called ‘Woody’s bar’. This enabled people to access fresh air and have barbeques. There had been an increase in activities and mental health awareness week was celebrated. People baked cakes and wrote on them to describe how they were feeling. A collage had also been created with regards to the impact of Covid 19 on people’s mental health. The four seasons were the focus with winter being the start of the pandemic and summer being where things have changed for the future.

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The service ensures people have been tested for COVID-19 before the service agrees to admit them.

Residents are assessed daily for the development of a high temperature (37.8°C or above), a cough, as well as for softer signs such as shortness of breath, loss of appetite, confusion, diarrhoea or vomiting.

Staff helped people to stay in touch with family and friends through phone and video calls.

The manager was communicating with people, staff and family members regularly to make sure everyone had an understanding of precautions being taken, and how to keep people safe.

Further information is in the detailed findings below.

Woodtown House is a nursing home in one adapted building providing personal and nursing care to 14 people with mental health difficulties at the time of the inspection. The service can support up to 28 people.

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

The service now had a registered manager in post since October 2019. Until then, there had not been a registered manager since March 2016, with several managers coming and going. As a result, there had been a clear lack of leadership, oversight and scrutiny of the service.

Robust audits had now been implemented following guidance from the Quality Assurance Improvement Team (QAIT) of the local authority, which needed to be fully embedded in practice as the registered manager had only been in post for a short period of time.

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; the policies and systems in the service supported this practice.

The service provided safe care to people. People felt safe and supported by staff. Comments included: “I feel safe here.” Comprehensive risk assessments were in place. Medicines were safely managed on people’s behalf.

Care files were personalised to reflect people’s personal preferences. People were supported to maintain a balanced diet. Health and social care professionals were regularly involved in people’s care to ensure they received the care and treatment which was right for them.

Staff relationships with people were caring and supportive. Staff treated people with dignity and respect when helping them with daily living tasks. The service ensured people led meaningful and fulfilled lives.

There were safe staff recruitment and selection processes in place. People received effective care and support from staff who were well trained and competent.

Staff spoke positively about communication and how the registered manager worked well with them and encouraged their professional development.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 11 June 2019) and there were three breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People’s needs were at risk of not being fully met because of reduced staffing levels. We judged that with the reduction in staffing plus the high number of agency workers, there was an increased risk that people’s needs were at risk of not being met. We fed this back to the provider who agreed that they would immediately re-instate the staffing numbers back to one senior or nurse plus three care staff.

People with nursing needs were at risk of having their needs unmet because the providers continued to struggle to get nurse cover, but their contingency plan was to have one nurse at least across one shift i.e. one 24-hour period. During other times they would have a senior support worker who was trained to give medicines. The provider said they have looked at ways to attract more nurses. To date they were still reliant on using agency senior support workers and sometimes this was for more than their own contingency of 24 hours. Some shifts had gone for two days without nurse input.

We raised some concerns around “as required medicine practices”. This was addressed quickly by the provider to ensure these practices were improved. This should have been picked up by the provider’s quality assurance systems and by having more nurses available.

We identified some issues with fire safety and have referred this on to Devon Fire and Rescue Services.

We were made aware that some people struggled to access the service’s vehicle safely and were using the wheelchair ramp which was an unsafe practice.

Communication between the provider and the service appeared to be an issue and this had the potential to place people at risk.

The providers quality assurance system was not always effective or had led to enough improvements which placed people at risk of inappropriate care.

We have issued two requirements in relation to staffing and to good governance.

More information is in the full report

Rating at last inspection: Requires Improvement in all key questions except caring which was rated as good. Overall rating of requires improvement. Report published November 2018.

Why we inspected: We completed this focussed inspection because we had received some information of concern about staffing levels and people’s safety. We looked at two key areas, Safe and well led during this inspection. At the last inspection these areas were rated requires improvement. At this inspection we have judged that well-led had deteriorated to inadequate. Safe remains requires improvement.

Enforcement: Action we told provider to take. We have told he provider to keep the staffing level under review and ensure nursing cover is consistent. We have issued two requirements notices in relation to regulation 18 - having sufficient and suitably qualified staff, and 17- good governance.

Follow up: We will continue to monitor the intelligence we receive about the service. We will continue to liaise with the local Authority safeguarding team, commissioners and the providers to ensure people’s safety. We will complete a comprehensive inspection within the next six months. If any concerning information is received, we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Woodtown House 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. Woodtown House provides accommodation and personal care to a maximum of 28 people with a past or present mental illness in one adapted building. At the time of our inspection there were 16 people living at the service.

This inspection was brought forward due to concerns raised by health and social care professionals about the lack of nursing cover on each shift; staff’s lack of understanding of people’s needs; poor documentation; lack of meaningful occupation for people and poor leadership and quality monitoring. As a result, a safeguarding meeting was held on 6 September 2018. The outcome of the meeting was that Woodtown House met the threshold for whole home safeguarding. This meant an increased oversight and scrutiny by health and social care professionals to ensure people were receiving appropriate care and support.

At the last inspection in May 2016, the service was rated as good overall. This inspection the overall rating has declined to requires improvement in safe, effective, responsive and well-led. Caring remains good.

There has been no registered manager in post since March 2016. 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. There had been various managers in post since 2016 but none of them had gone on to register with CQC, despite them stating to the provider they were in the process of registering. The new manager was currently in the process of registering to become the registered manager.

Both people, staff and health and social care professionals felt there was a lack of meaningful activities on offer to aid people’s mental health well-being. Daily notes also lacked detail about people’s mental health well-being. For example, notes stated: ‘Has been out…, unsettled when they returned and very vocal during mealtimes. Advised to eat in another room. Experiencing distressing thought disorder…’; ‘Awake early and went out… Returned agitated, very confrontational’ and ‘Out for much of the day… On returning they seemed quite upset and frustrated.’ None of these entries went into detail about what was distressing them, what support was offered or any interventions to help them with their mental health difficulties. We discussed both the lack of meaningful activities and detail in daily notes with the manager and provider, both agreed the lack of detail in daily notes would not enable any care plans to be updated with what helps at times of distress to guide staff appropriately.

The quality of the service was not continually monitored and improved. There was a clear lack of leadership, oversight and scrutiny of the service. Staff spoke about how it had been difficult with managers coming and going, with it being unsettling at times. However, they spoke positively about how they had worked as a team. The provider explained how they had recognised that the leadership at Woodtown House was not strong enough. As a result, they had increased the regional support provided to the service from once a month to every two weeks. A registered manager from another of the provider’s services also spent increased time at the home to provide some stability to the staff team.

Staffing levels met people’s personal care needs. However, meaningful interactions were limited. We recommend the deployment of staff is managed more effectively in order for people to be able to engage in social activities. The service was also currently struggling to recruit a registered nurse, despite every effort having been undertaken. For example, via job searching websites and a recruitment agency. As a result, on occasions there was no registered nurse on duty. Due to the difficulty, the provider had made the decision to train senior support workers to run certain shifts and administer people’s medicines with a registered nurse on-call.

Necessary online training topics were not up to date. Staff were knowledgeable, however due to the nature of the service and the people’s complex needs this needed to be improved. For some new staff their induction had not been adequate enough for them to develop their skills of the service and the people living there. Due to management changes, staff had not received an up to date appraisal since July 2017.

The service provided safe care to people. One person commented: “I feel safe here” Measures to manage risk were as least restrictive as possible to protect people’s freedom. People’s rights were protected because the service followed the appropriate legal processes. Medicines were safely managed on people’s behalf.

People received a nutritious and balance diet and enjoyed the meals. However, monitoring of people’s weights had not always been completed. This potentially put people at risk of malnutrition.

Woodtown House continued to provide a caring service to people and was very much people's home. People had built strong relationships with staff. There was a happy atmosphere. People commented: “The staff are very caring” and “The cares good.”

There were regular opportunities for people and people that matter to them to raise issues, concerns and compliments.

We found two breaches of Regulations in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We have also made two recommendations.

Further information is in the detailed findings below.

Woodtown House is registered to provide 24 hour nursing care to 28 people with a past or present mental illness. At the time of our inspection there were 23 people living at Woodtown House.

There was no 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. The manager had started the process of registering, but due to personal circumstances was now not going to proceed with registration. The previous registered manager still worked for the organisation as a clinical director and continued to support the home. We were assured that measures were in place to manage the service whilst they recruited. These measures included, the deputy manager stepping into the role, supported by both the clinical lead and clinical director.

The organisation recognised the importance of staff receiving regular support to carry out their roles safely. However, due to management changes between spring and autumn of 2015, staff had not been receiving formal supervision to identify any specific needs. Staff did confirm they felt supported at this time due to the strong team working which took place. The manager had recognised this deficit and a supervision schedule had been developed. The schedule confirmed that the majority of staff had received supervision in May 2016.

There were effective staff recruitment and selection processes in place. Staffing arrangements were flexible in order to meet people’s individual needs. Staff received a range of training to keep their skills up to date in order to support people appropriately. Staff spoke positively about communication and how the manager worked well with them, encouraged team working and an open culture.

People felt safe and staff demonstrated a good understanding of what constituted abuse and how to report if concerns were raised. Measures to manage risk were as least restrictive as possible to protect people’s freedom. People’s rights were protected because the service followed the appropriate legal processes. Medicines were safely managed on people’s behalf.

Care files were personalised to reflect people’s personal preferences. Their views and suggestions were taken into account to improve the service. They were supported to maintain a balanced diet, which they enjoyed. Health and social care professionals were regularly involved in people’s care to ensure they received the care and treatment which was right for them.

Staff relationships with people were caring and supportive. Staff were motivated and inspired to offer care that was kind and compassionate. People engaged in a variety of activities and spent time in the local community going to specific places of interest.

A number of effective methods were used to assess the quality and safety of the service people received.

People commented that they were fully involved and supported to make decisions about their care. For example, plans of care were reviewed with people living at Woodtown House involved and their needs and wishes were taken into account.

We spent time talking to people who lived at Woodtown House and observing the interactions between them and staff. Comments included: 'The staff consider my welfare'; 'I went out shopping yesterday, I do lots of activities with staff support' and 'It's alright here and the foods good.' During our visit, we saw that people appeared relaxed and contented.

Medicines were safely administered. We saw the medication recording records which were appropriately signed by staff when administering a person's medication.

We observed that staff were well organised, motivated and competent in their roles. Staff provided support in a caring manner making sure that people were comfortable and content.

People's personal details were kept securely to preserve confidentiality. Staff confirmed that they had ready access to people's care records when needed.

We spoke to people about how staff gained consent from them before providing care or treatment. Comments included: 'The staff ask me before helping me' and 'I am always asked if I am ready to take my medication.'

People said that their care and welfare needs were being well met. Comments included: 'I am well looked after'; 'The staff are lovely here, so helpful' and 'We do activities, I like skittles and monopoly.' We observed people living at the home and staff. We saw plenty of positive interactions taking place and people looked relaxed and comfortable asking staff for advice or information.

People confirmed that they felt safe and supported by staff at Woodtown House and had no concerns about the ability of staff to respond to safeguarding concerns. They felt that their human rights were upheld and respected by staff.

People informed us that staff met their needs in a timely manner. Everyone we spoke with were confident in the ability of staff to provide the care needed.