Background to this inspection
Updated
1 June 2022
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
This inspection was undertaken by one inspector.
Service and service type
Woodbridge Lodge Residential Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. [Care home name] is a care home [with/without] nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
At the time of our inspection there was manager registered at the service, but they had recently left on 16 April 2022 due to retirement. The provider's operations manager was overseeing the management of the service until a permanent manager could be recruited. We have referred to them as the operations manager throughout the report.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used all this information to plan our inspection.
During the inspection
During our inspection visit on 27 April 2022 we spoke with five people who used the service and two relatives about their experiences. We also observed staff interactions during lunch. We spoke with five staff members including two operations managers, head of care, senior care staff and activities staff, we also briefly spoke with the maintenance staff member. We reviewed medicines management and records relating to staff recruitment, health and safety and governance.
Following our visit, we received feedback on the telephone or electronically from 10 relatives and 11 staff members, including senior care staff, support workers, catering and domestic staff. We reviewed the care records of six people, including their care plans, risk assessments and medicine administration records. We also reviewed records relating to the governance and management of the service including audits.
On 12 May 2022 we fed back our findings, via a video call, to three of the provider's operations managers.
Updated
1 June 2022
About the service
Woodbridge Lodge Residential Home is a residential care home providing personal care to up to 32 people. The service provides support to older people, some living with dementia. The service is provided in one adapted building over three floors. At the time of our inspection there were 28 people using the service.
People’s experience of using this service and what we found
The registered manager had retired 11 days before our inspection visit. The provider had advertised for a new manager and the service was being managed by the provider’s operations manager and other members of the provider’s operations management team.
The service was working with stakeholders, were in the process of improving the service and had an action plan in place. However, not all of these improvements were fully implemented and embedded in practice.
The governance systems were not robust enough to support the provider and management team to independently identify shortfalls and address them. Improvements were being made in this area.
The systems in place to assess and mitigate risk were not always robust enough to keep people safe from abuse and avoidable harm. People were not always receiving their medicines as prescribed. We found bed linen was not always clean and hygienic. We were assured by the operations team these shortfalls were being addressed.
Staff had been recruited safely and the provider had a system in place to calculate the numbers of staff needed to meet people's needs. We received mixed views from staff and relatives relating to the staffing numbers in the service. Improvements were being made in the deployment of staff around the service to be present to support and make checks on people on all floors.
The provider had risk assessments and policies relating to the COVID-19 pandemic. People were supported to have visitors. 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.
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 12 December 2019).
Why we inspected
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.
The inspection was prompted in part by notification of a specific incident. Following which a person using the service died. This incident is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident. The information CQC received about the incident indicated concerns about the management of skin care and diabetes. This inspection examined those risks.
We received concerns in relation to pressure ulcer management, staffing, records, safe care and treatment and the overall governance of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has changed from good to requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report. 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 Woodbridge Lodge Residential Home 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 monitor the service and will take further action if needed.
We have identified breaches in relation to safe care and treatment and good governance at this inspection. Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.