Woodbury House

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 assessed a limited number of quality statements in the safe key question and found areas of concern. The scores for these areas have been combined with scores based on the rating from the last inspection, requires improvement. We identified 3 breaches of the legal regulations in relation to safe care and treatment, staffing and notifying the CQC of other incidents. People were at risk of harm due to unsafe moving and handling practices. The service did not take action to mitigate known risks of choking, falls and communication to people which meant people did not always receive safe care and treatment. The service did not ensure the premises and equipment were safe to use for their intended purpose or were used in a safe way. The service did not inform the CQC there was just one hoist battery on the premises for 3 hoists. Information within the care records was not always easily accessible. This meant people were at risk of unsafe care as information was not always accessible to support safe care and treatment for people. Staff did not have the appropriate guidance and support to provide safe care and treatment for people. Some training was overdue. Leaders did not ensure there were sufficient numbers of suitably qualified, competent, skilled and experienced persons to meet the needs of the people using the service to deliver safe care that promoted choice, control and individual wellbeing. Systems, processes and practices did not always ensure that people’s human rights were upheld and they were protected from abuse, discrimination, avoidable harm and neglect.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We found people were not always protected from avoidable harm and neglect. We received mixed feedback from people and their relatives about the care they received. A person told us they raised concerns during the night but staff were slow to respond to their request for support. One person told us about the poor care they experienced when being supported with their personal care. They told us they were left alone at one point and cold water was used to wash their hair. The person told us they did not report this incident as they were, “Scared it may cause trouble.” We asked the person how they would ask for help as we observed there was no call bell in the room. The person told us they were unsure and they would call out for help. We were told by a person, “Up here is the problem, nobody seems to like me, and I don’t know why.” However, we also received positive feedback from people who told us they felt safe with the care provided with staff, saying all were very good and nice. Relatives told us of their concerns in relation to equipment, staffing, issues with the batteries for the hoists and their loved one’s water jug not being filled for a whole day. We received mixed feedback from relatives in relation to the safety of their loved ones. Some said their family member was safe, but another relative was, “80% certain” about their loved one’s safety. A relative told us the staff were kind and caring.

Staff told us they learnt about keeping people safe from abuse, preventing them from harm as much as they could without restricting them, protecting them and respecting their dignity. We were also told staff were, “Going to be given training on safeguarding and given an email address where we can report things, if we see something wrong and nobody listens, we can report it.” Leaders told us, “Home Managers and Staff are trained in their responsibilities for reporting and recording concerns about abuse / neglect etc” and, “There are always enough staff on duty with the correct knowledge, skills, personality and experience to ensure residents are safe.” Leaders also told us, “All staff are provided with safeguarding training.” However, observations, feedback received, systems, processes and practices reviewed did not always ensure that people’s human rights were upheld and they were protected from abuse, discrimination, avoidable harm and neglect.

We observed staff were not effectively deployed across the home to meet people’s care and treatment needs. We observed not everyone had drinks available and some drinks were not within reach of the person. Our observations at lunchtime identified there was a lack of staff in the dining room. We observed a person pressing their bell, a nurse appeared to see where the alarm was and then walked past the person’s room to find a member of staff to come and ask what was wrong with the person and what they needed. A member of staff was observed going into a person’s room and reading out the full menu for them to make a choice. However, the person seemed to be overwhelmed by this which made it difficult for them to make an informed choice. There was a menu on dining room tables, but the print was difficult for people to read. There were no pictures of the food on offer and no example plates made up to demonstrate possible food choices. There was minimal interaction between people and staff on the ground and first floors. We observed a person sitting alone in the dining room without any staff interaction for up to 20 minutes. However, we observed people taking part in a game with bean bags on the second floor.

We noted there was currently only one battery for all 3 hoists in the home. We drew this to the attention of the registered manager who told us they were unaware of this. They later confirmed that the home was operating with just one battery for the previous 5 days. At the inspector’s request, this was escalated by the registered manager and 2 additional batteries were on site before the end of the assessment day. The provider did not submit a notification related to this event, which affected their ability to continue to carry on the regulated activity in a safe way, in a timely manner. We noted the call bells were not always within reach of people and we noted from a person’s care records observations were not carried out in accordance with their assessed needs. One person’s pre-admission assessment stated a sensor mat was required and we observed there was no sensor mat in their room. There was conflicting information recorded within a person’s care records as to whether the person could use their call bell. There was no guidance for staff as to how the person would request help and support when required or how they were to be supported with their communication needs. Information held in people’s care plan folders was not always easy to locate. There was little consistency as to where documents were held. For example, we found one person’s review document located in the medication section of their folder. Key documents relating to people’s safety were difficult to locate. A leader told us the care plans were cumbersome. This meant that documents related to people’s safety would not be easily accessible to staff in an emergency.

People were not always supported by robust risk management. We received mixed feedback from people’s relatives about how risks were managed. One person told us their loved one required a sling when being transferred from bed and chair, but it was not the right size. We were also told, “The one [sling] that they had that was right for them was taken away. Everything seems to take so long from an issue being raised and it being resolved.” The relative told us this was distressing for their loved one and they were slipping through the extra large one and the one before that was too small. We raised the issue of the sling with the leaders and we asked them to confirm the person had the correct sling in order for them to carry out moving and handling safely. The leaders informed us the person had the correct sling in place and they had ordered additional slings as they, “Noticed some staining on a couple of slings that had not come out in the wash and because some residents could do with an extra sling.” We were also told by a relative there were no low toilets in the bathrooms which was an issue for their loved one who could only use a low toilet. However, some relatives told us they felt risks were managed and their loved one, “Had falls which were immediately dealt with, moved to a room where they can be kept a closer eye on.”

Staff told us they, “Assess the risk involving any decision that should be taken. Weigh the risk” and they used daily flash meetings to discuss any concerns with people. Staff also told us they, “Need to get consent and introduce yourself, explain the procedure to them and why you are doing them.” Leaders told us, “We must always take a balanced and proportionate approach to risk management” and, “We must also manage communication relating to needs, emotions or distress sensitively / positively.” However, through observations, feedback received, systems, processes and practices reviewed, we found the service did not always ensure risks were well managed to meet people’s needs in a way that was safe, supportive and mitigated risks.

During our observations an external professional told us they go into people’s rooms and will move them if needed. We later confirmed they were not trained to provide this support. When we raised this with the leaders, they advised us they would get moving and handling training for the professional. We observed a person’s room door handle had come off and we and the person informed a staff member of this. We observed the padlock was unlocked for the cupboard with the stop cocks for hot and cold water on the first floor. We observed the linen cupboard on the first floor was unlocked and there was a sign on this door that said, “Fire door keep locked.” We observed there were ladders stored outside that were not chained which could give anyone access to the building. A member of staff told us this was where they were ordinarily stored. We observed a communal bathroom which had an open door allowing access to anyone. In this bathroom, we observed items lying around including screws and fittings. We observed the sluice room with the door open (on the first floor) which had soiled items and accessible machinery. This meant people were at risk as the premises and equipment used by the service provider were not safe to use for their intended purpose nor used in a safe way.

The provider’s systems and processes to ensure certain risks to people were assessed, managed and mitigated safely were not always consistently applied. We identified conflicting and missing information within a person’s choking care records. We also identified care records were not updated accurately to reflect changes in relation to choking risks. Therefore, staff did not have the correct information in all documents to support people safely to mitigate known risks of choking. We identified for a person, their falls record had not been completed accurately. We informed the leaders information was not always accessible in the care plan folders and it was difficult to find information. A leader told us the care plans were cumbersome. Therefore, staff did not always have the correct information to support people safely to reduce risks. We informed the leaders of the external professional informing us of moving and handling people. The leaders told us they would arrange moving and handling training for the external professional. Therefore, people were put at an increased risk of harm, as not all staff working with people had the appropriate training in supporting people to mobilise safely.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

There were not enough qualified, skilled and experienced staff to provide safe care that met people’s individual needs. People were put at an increased risk of harm, as not all staff working with people had the appropriate training to support people safely. A person told us, “At the moment they are short staffed, I felt pain this morning and wasn’t going to do anything about it but the cleaner raised it to the nurse.” The person told us they, “Would have been waiting for the nurse to do the medication round.” Relatives told us, “I think some of the healthcare assistants might need a little more training perhaps in terms of assertiveness, but they all appear very kind” and, “I feel like there is not enough of any staff to keep the place running smoothly.” Relatives told us there were not enough staff. One person’s relative told us their family member was waiting for their breakfast and had to wait a long time to be settled in bed due to the lack of staff. We were informed by a relative, “Where the service falls down is the management above [registered manager].” However, relatives told us the registered manager was “Brilliant,” had an open door policy and all staff were approachable.

Whilst staff told us there were enough staff to provide safe care, views expressed by people and their relatives, as well as our observations demonstrated there were not sufficient staff to provide safe and effective care. Staff told us they shared work out through the team and the staff worked together as a team. In relation to agency staff, staff told us of their concerns of agency staff not knowing the people, documentation was not completed to the required standard and when hourly observations were required, if the agency staff were not prompted, they were, “Likely to overlook them.” Staff were not always able to describe to us how they applied learning which was part of their mandatory training. For example, when we asked staff of their understanding of the Mental Capacity Act, some told us they were, “Not familiar with doing any training recently” and, “I have only had moving and handling and fire safety training. I don’t really understand that.” They were also unable to describe what Deprivation of Liberty Safeguards (DoLS) meant, “I do not know what that is” and, “I do not know what DoLS is.” Leaders told us, “There are also enough qualified, skills and experienced staff at all times.” Leaders also told us, “Staff work well together as a team, but this is an ongoing piece of work and as such staff must be monitored and reviewed regularly.” However, we observed there was an absence of staff throughout the day, across the home. This was fed back to the leaders. The registered manager informed CQC they would action a walkaround several times a day commencing the day following our site visit, action a, “Meet and greet” and monitor staff presence. However, observations, feedback received, systems, processes and practices reviewed did not always ensure the service provided sufficient numbers of suitably qualified, competent, skilled and experienced persons to meet the needs of the people using the service.

We observed a significant lack of staff throughout the whole assessment day. At one point, there was no member of staff on the top floor, where people were confined to their rooms and some were unable to access their call bell. We heard staff explain to people they would have to wait to be supported. During our observations at lunchtime, we heard a member of staff refusing to take a person to the bathroom. The person was told, “You will have to wait because I am the only member of staff here at the moment.” When we asked a member of staff about the absence of staff, their reply was, “I don’t know but I am here now.”

The provider failed to ensure there were enough qualified, skilled and experienced staff to meet people’s individual needs. The staff training record identified some training was overdue for some staff. This included safeguarding training, mental capacity act and deprivation of liberty training, fire drill training, fire evacuation training, fire safety training. This meant people were at risk as not all staff had received the training to enable them to carry out the duties they were employed to perform. We observed there was an absence of staff throughout the day, across the home. Rotas did not always reflect the number of staff the leaders informed us were required to support people. The leaders told us they used a dependency tool to inform the number of staff required. However, they were unable to share this.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.