Woodroffe Benton House

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• 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

The overall rating for this key question is requires improvement. We identified areas of improvement and breaches of regulation in respect of safeguarding and safe care and treatment. Medicines were not always stored and managed safely; people did not always receive their medicines at the right time and in line with the prescriber’s guidance. People were not always protected from the risk of abuse, staff understood how and who to report concerns to internally and externally of the service, however, managers did not always appropriately escalate concerns to the local authority. Staff and management did not always learn from audits, adverse events, incidents and accidents. Incidents were not always responded to appropriately and lessons were not always learned to avoid reoccurrence. People and their relatives were not always involved with planning their care and support, including managing risks. Staff were provided with guidance to support people, however, the guidance was not always up to date and accurate. People told us staff were sometimes rushed at times but said their needs were met, however, we observed enough staff during our visits. Staff were recruited safely and regularly supervised. Staff mostly received training relevant to their role and were able to request further training for ongoing development. People were protected by staff who followed infection prevention and control measures. The service was clean and staff followed policy in respect of personal protective equipment and hand washing. The environment and equipment to support people was well maintained.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they could speak up if something had gone wrong for them and they would be listened to. A person commented, “The only incident I am aware of was when a carer was rude to me. My daughter spoke to the manager and the carer came and apologised.” While the people we spoke with expressed that they were generally happy with their care, our assessment found elements of care did not meet the expected standards.

The registered manager had devised checks and documents to oversee accidents and incidents, they told us they signed off accident reports and added the event to a tracker. However, they failed to undertake investigations and learn lessons from some accidents and incidents by not ascertaining facts and speaking with people and staff at the time, or shortly after the incident was reported. Staff gave examples about falls and how they learned lessons to prevent similar incidents. One staff member told us, “They (management) do make changes to improve, like checking the resident more often or to give a sensor mat.”

Processes were in place to monitor and analyse incidents and accidents, but they were not always used effectively. We saw action was not always taken in response to individual incidents including where people displayed emotions of distress. There were records where a person became anxious and hit out during personal care and showering, this happened on multiple occasions. This had not been recognised as a trend and therefore, the person’s care records were not updated to guide staff on how best to the support them and minimise anxiety. Some lessons were learned in responses to incidents. For example, following a concern after a moving and positioning incident, staff underwent extensive training. Instructions were also placed on the back of people's doors to clarify for staff which sling they required and what loops to use for hoist safety. The registered manager identified the need for hooks to be put on bathroom doors to ensure the correct hoist slings were available for individuals. This was to avoid slings going missing and the wrong sling being used for people.

People did not always receive a continuity of care when admitted to the service. A person who moved into the service required healthcare professional involvement. The referral had not been completed by their previous placement which caused a delay in healthcare professional review, staff did not follow the referral up for 7 days which comprised the person’s wound management.

A member of staff was allocated to complete assessments prior to people moving into the service, they told us of the importance of meeting the person beforehand so they may recognise staff upon admission. A staff member told us about a person who was due to be admitted to the service and required an air mattress. Their admission was delayed until the mattress had been sourced by staff with health and social care professional involvement. This ensured the person remained supported with the right equipment to meet their needs.

Health and social care professionals gave mixed feedback about how managers and staff worked with them to promote safe systems and pathways for people. A healthcare professional commented, “Following an assessment of a resident, the home were advised to purchase a new sling for the resident which they did. They were advised to update the care plan accordingly, to ensure specific detail relating to the hoisting procedure and sling detail was included in the care plan. They did this.” Another told us, “If I am assessing someone with memory issues I need to ask staff and often they don’t know. Very often the care plans are misleading as they don’t update as the residents health changes, I am hearing [member of the management team] is working on it and there are a lot of system changes.” Visiting professionals gave examples of medicine errors which had been made following hospital discharge as staff had not always accurately followed medicine changes and instructions for people.

People’s needs were assessed prior to moving into the service. A member of staff completed assessment at people’s homes or if required, at hospital. People were involved in their assessments and specified likes and dislikes, where people required support from health or social care professionals, this was noted in the assessment, however, referrals were not always followed up. A one page profile was in place should a person move to another service or require admission to hospital. This documentation was completed to assist new care providers to provide continuity of care for people.

People told us they felt safe within the service and should they not, they would speak with staff or management. One person told us, “I do feel safe there is always someone around if you need them.” While the people we spoke with expressed that they were generally happy with their care, our assessment found elements of care did not meet the expected standards.

Staff had received safeguarding training and demonstrated an understanding of types of abuse and what they would report to management. A staff member told us, “I had training, I would report if I saw someone grab a resident or bruises. This does not happen here, I would report to a senior and the manager. I would call CQC if they did nothing.” Staff documented concerns about people, for example, if they noted any bruises or injuries. However, the management team did not always investigate the incidents and escalate concerns to the local authority safeguarding team.

We observed staff supporting people kindly and people appeared comfortable in the presence of staff. It was difficult to determine whether people who had deprivation of liberty (DoLS) authorisation were being supported appropriately as it was not clear who was subject to an authorisation, we did not observe anyone trying to leave the service.

Staff and management did not always work within the principles of the Mental Capacity Act 2005 (MCA). People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, this is through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). DoLS applications were not always completed in a timely way. There was no process in place for the registered manager to ensure conditions of people’s DoLS authorisations were being met. A DoLS tracker was devised, however, this had not been completed in it’s entirely and was not kept up to date. This meant, people were at risk of being unlawfully restricted. The registered manager responded to these concerns and told us the DoLS tracker would be updated imminently and people who lacked capacity were being reassessed for a DoLS application. The provider’s systems to safeguard people from the risk of harm or abuse was not always followed. We identified incidents which had not been escalated to the local safeguarding team. We raised 5 safeguarding alerts to the local authority regarding unexplained bruises during the assessment.

Some people required staff support or equipment to help them move from room to room. When speaking about the support they required, people told us, “I get the help I need, which is someone by my side when I am walking using my frame, they make sure I have drinks and call bell when I am in my room and my book.” And, “The main help I have is transferring between chair and bed, the hoist is a necessary evil but they (staff) manage it well.” People told us, although staff supported them inline with their wishes, they were not involved with the formulation of their care plans and risk assessments. People were not given the opportunity to formally record their views in relation to risk management, due to the use of agency staff and newer staff joining the service, people were at risk of experiencing inconsistent support.

Staff gave examples of how they ensured people were safe when using equipment. A staff member said, “When I am hoisting, first we need 2 people, make sure the sling is correctly with the correct loops, I always check date of sling expiry, I check the strap. Sometimes the seams are not good, I say don’t use. I am checking with my eyes, being careful not to bruise people.” When speaking about the availability of information about people’s care needs, a staff member said, “I check the care plan, if I don’t find the information I go to seniors, normally they have enough information.”

We observed staff supporting people to move from the lounge to the dining room. People were assisted with the equipment safely, for example, a person was hoisted from their chair to a wheelchair, this was completed with good communication between staff and the person. Another person was supported to use a stand-aid, they appeared comfortable and confident with staff guiding them on each step.

A member of the management team advised us people’s care plans and risk assessments were out of date and did not contain much information. We requested to see some peoples’ care records, in the time between our request and when they were sent the care records had been updated. It is therefore, not clear the level of information that was available to staff during our first visit. However, the updated care records we reviewed contained enough information for staff to safely support people. Where people were known to become anxious or display emotions of distress, care plans and risk assessments were not in place to guide staff on how to safely support them. Staff practices did not always align to their planned care. For example, a person was assessed to require prompting with personal care and to shower by one staff member, however, they were sometimes assisted and supported by two staff. During this time, they showed distress by hitting out at staff, their care records did not reflect that they may become upset when being supported with personal care and there was no guidance for staff on how to support the person when this happened.

People told us they were happy with the environment, they commented about the spaces they could use within the service. one person said, “My daughter visits and we usually sit in my room or the quiet room so we can chat and laugh without disturbing anyone else.” Another person spoke about their room and said, “I wish we had carpeted rooms but I can see the point of not having them.”

Management and the maintenance team ensured the environment was safe for people. When speaking about improvements to the environment, a staff member said, “Head office listen to me and I can make any suggestions.” The registered manager told us of changes made to the flooring in the corridors to ensure it was flat and safe for people to walk on.

We observed the environment to be clean and generally safe, however, the communal spaces were not homely. A member of the senior management team told us they were aware of areas which looked clinical and shared extensive plans of making the service more homely and suitable for people living with dementia. Consideration was not always given to people who lived with dementia who required orientation around the service. For example, people’s names were displayed on their doors but no pictorial references to help people recognise their space, one person’s name had been misspelled. There were posters displayed in communal areas for staff. For example, posters on ‘challenging behaviour’, this did not provide a homely environment for the people living at the service. However, some areas were homely, people’s artwork was displayed in the corridors and their bedrooms were mostly personalised.

Processes were in place to ensure the safety of the premises and equipment. The senior management team worked with the registered manager and maintenance team to ensure health and safety checks were completed and to rectify any shortfalls. The service improvement plan clearly set out proposals to enhance the environment. Regular checks were completed, for example, checks on the risks of Legionnaires and checks of equipment, such as, hoists and slings. West Sussex Fire and Rescue Service had completed an audit, an action plan had been drawn up which reflected the findings from the audit. The maintenance team worked through the action plan and had met the clear timeframe of when shortfalls were to be completed.

People spoke positively about the staff; however, some people told us they felt there was not always enough staff on duty. A person told us, “I think they could do with a few more, I have a call bell and when I ring they come as fast as they can, I mean if they are working with someone else it will be slow, if I am in the lounge and I yell they come very quickly, I would love it if they had more time to chat and some do take more time.” Another person said, “There will always be times when they could do with more but mostly it is fine, they answer bells as soon as they can.”

Staff worked across Woodroffe Benton House and another of the provider’s services which was within the same grounds. Some staff worked a variety of shifts over the two services and told us they were not always well versed in people’s individual needs. We received mixed feedback from staff about staffing levels. One staff commented, “No there is not (enough staff), we don’t have kitchen staff in the afternoon, it is only 3 of us and one of us has to be in the kitchen washing the plates. After supper we need to help residents. Some are high risks and try to stand up. This is 3 carers and a senior but the seniors don’t help us, just give us orders.” Another staff member said, “Normally it is fine, we normally have enough.” Staff said they had enough training opportunities to support them in their roles. A staff member said, “They’ve (staff) just all had a load of manual handling training, I did dysphagia (swallowing difficulty) training, it’s all recent.”

We observed there were enough staff to support people during the day of our assessment. However, on the first day of our assessment, some ancillary staff were on annual leave which meant during the busy morning period, a staff member was administering medicines but had to stop to assist a visiting health care professional. This caused a delay in people being administered their medicines. Throughout our assessment visits, staff appeared busy but not rushed and responded to people’s requests in a timely way. Staff had enough time to support people with their meals and general day to day activities.

Staff were recruited safely, pre-employment checks had been carried out prior to their employment, this included references, background checks and the right to work in the UK. The registered manager used a dependency tool to assess how many staff were required to meet people's needs. Some agency staff were deployed to cover shortfalls in the rota. The call bell audit showed bells were answered in a timely way, however, a person told us, “They need some more (staff), they work very hard and are always in a rush, if I call they come as fast as they can but sometimes they dash in turn the bell off and come back later.” Staff were given training opportunities which were relevant to their roles. Some senior staff were upskilled to train other staff, for example, some staff had completed a ‘train the trainer’ course in moving and positioning. This ensured training could be delivered in a timely way to new staff and staff who required more support and supervision. Staff commented positively on the training provided by a member of the management team.

People told us they were happy with the cleanliness at the service. Comments included, “I dust my room a bit but the cleaner is lovely and in general the place is spotless.” And, “It is very good, the cleaner is excellent.”

Staff had received training in infection prevention and control and practiced what they had learned. A staff member told us they always had enough cleaning stocks and described additional personal protective equipment (PPE) they would use in the event of any outbreak.

The service was clean, housekeeping staff followed schedules to ensure bedrooms, bathrooms and communal space were cleaned on a regular basis. We observed staff using and disposing their PPE appropriately. The laundry was tidy and well organised by a dedicated laundry team. We observed housekeeping and laundry staff working hard to keep the service hygienic and free from odours.

Staff and mangers completed checks and audits to comply with the provider’s infection prevention and control (IPC) policy. The registered manager introduced further checks to ensure a good standard of cleanliness, these included mattress checks and kitchen audits.

People were not always receiving their medicines safely and as prescribed. People's stock of medicines was sometimes unavailable, staff were not always responsive in ensuring these medicines were re-ordered and made available in a timely way, this meant on some occasions people did not receive their prescribed medicines. ‘When required’ (PRN) medicines were sometimes given routinely with no record for why it was needed, if it had been effective or if the service had escalated regular use to the prescriber. People who were prescribed medicines with additional administration requirements were not always having this followed. This placed them at risk of experiencing unwanted side effects. People told us about how their medicines were managed. Comments included, “As far as I know my tablets are given correctly.” Another person said, “I came in on one tablet a day which they have stopped and put me on about 6 morning and evening but I don’t know what they are for.” While the people we spoke to expressed that they were generally happy with their care, our assessment found elements of care did not meet the expected standards.

Staff were trained and checked for competency routinely when administering medicines. However, recent changes to the medicines administration and recording process had not been done alongside refreshed training and competencies. This resulted in staff making errors and omissions when administering medicines. There were no clear plans in place to share learning from these incidents with staff to prevent recurrence. Weekly audits and checks that staff were expected to do to identify errors and near misses were not always taking place. This meant errors could continue for an extended time before being acted on. A staff member told us how they reported errors and said, “With a medicine error, I would do a medication error form and let them (management) know. With lessons learned, as soon as we have errors across the board, [deputy manager] will let us know, there might be a memo, we are told if something has happened and we need to be more observant.”

There were policies and processes in place to ensure that people received medicines safely; these were supported by a paper-based medicines administration record. ‘When required’ PRN medicine protocols (documents which can support the safe and effective use of PRN medicines) were missing for many prescribed medicines. Sometimes those in place lacked detail to support staff to understand how and when to use the medicines safely. When staff were hand transcribing information on the administration records there was no check and counter signature by a second member of staff. Transcribing errors had been identified in the service in the months prior to the inspection and during the inspection. Failure to ensure that records are completed in line with the prescribers intentions could lead to avoidable errors. Medicines were not always being stored in line with the manufacturers recommendations. This had been identified in audits conducted by staff and managers; however, it was still not resolved at the time of the inspection. Some medicines were stored outside of the recommended temperature range; this could lead to medicines being ineffective.