Woofferton Residential Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Systems in place to check the quality of the service were not always effective. Quality checks were often informal and did not always identify discrepancies or concerns which meant action was not always taken to address them. For example, where risk assessments weren't in place, where information in care plans was inconsistent, where mental capacity assessments had not been completed and where professional input had not been sought when changes were made to medicines administration. Staffing allocation was not always sufficient to ensure people's needs were met safely. Staff told us the registered manager was approachable and supportive. Relatives told us the registered manager was approachable and communicated well with them. The registered manager supported staff to undertake additional qualifications to upskill themselves. Staff told us there was a positive culture in the home and we observed positive relationships between the registered manager, staff and people living at the home.

This service scored 61 (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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us the registered manager was supportive and led by example. Staff told us the registered manager was visible and supported with care when needed so they knew people well and knew the challenges of the role. Staff felt included and involved in the running of the home. One staff member told us, “I don't have team meetings but I am always linked into anything I need to know. It's done through email or social media. The registered manager always includes me so I am informed.” The registered manager told us they identified staff who could be upskilled and gave them opportunities for development. The registered manager addressed areas of poor culture if needed to improve the quality of care provided. Whilst the registered manager was experienced and knowledgeable about people and their needs, governance processes were not always effective which meant oversight of the service was not always adequate to ensure concerns were identified and action taken to address them.

Systems in place to review lessons learnt were minimal. The registered manager addressed issues informally with staff but processes were not always robust to ensure learning wasn’t missed. Team meetings to discuss updates and learning were not always frequent, although informal discussion was common amongst staff and the registered manager. The registered manager was transparent and open and honest to apologise if needed when things went wrong. Processes in place for recruitment focused on ensuring the right staff were recruited to meet people’s needs and included consideration of staff aspirations. However, some aspects of the recruitment process required improvement such as not keeping interview records.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager told us they checked the quality of the care provided but were unable to show us evidence of some checks. The registered manager acknowledged that a lot of governance processes were informal and were not always evidenced in writing. Where the registered manager did provide evidence of quality checks, they were not always thorough and did not always show actions that had been identified and follow up that had been undertaken. This meant the registered manager could not be assured that checks were consistent and concerns were identified and action taken to reduce risk to people. The registered manager told us whilst they took action in respect to following up with health professionals when needed, this was not always recorded. This meant they could not be assured appropriate action had been taken to escalate concerns or clarify information relating to people's health. The registered manager and staff generally understood their own roles and responsibilities. However, they were not always clear regarding their role in assessing mental capacity. The registered manager was not always clear regarding their responsibilities in relation to raising safeguarding referrals and submitting statutory notifications. However, this was discussed during the site visit and a safeguarding referral was raised and statutory notification submitted retrospectively. The registered manager took action with staff where needed to improve performance. The registered manager had a positive outlook to improving performance and care provided to people. They told us, "We all talk about things when it goes wrong. Every day we have a new scenario. We talk about the best way to overcome it and how to adapt our care. We then share it with one another how we do it”.

Governance systems were not always effective to check the quality of care provided at the home. Processes were often informal and there was a lack of evidence to show quality checks that had been undertaken. This meant the provider could not be assured whether concerns had been identified and appropriate action taken to address those concerns. Systems in place did not always identify where there were gaps or errors in care records. Systems failed to identify where mental capacity assessments had not been completed or where DoLS applications had not been made. Medicines audits failed to identify where protocols for 'when required' medicines were not accessible to staff and the reason for administration was not recorded or where medicines had not been administered as prescribed and this had not been followed up with a medical professional. Systems in place also failed to identify where risk assessments had not been completed for clinical risks such as diabetes and where PEEP's had not been updated to ensure people's current needs were reflected. The provider had failed to ensure systems were in place to monitor clinical risks such as bowel monitoring and when to escalate concerns. Systems in place to determine staffing levels were not always robust and did not always ensure sufficient staff were deployed to meet people's needs safely and effectively. Where we did see evidence of quality checks, it was not always clear what was specifically looked at. For example, the provider sent us evidence of care plan checks but this lacked detail and only recorded dates on which they were informally checked. This meant the provider could not be assured that checks were undertaken consistently and in a way that ensured any concerns were identified. The provider did not implement action plans to ensure any oustanding tasks had been completed.The registered manager told us they did not have an action plan as they just dealt with actions when needed.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us the registered manager openly asked them to put forward their ideas to improve the home. One staff member told us, “The manager is happy for us to make suggestions”. The registered manager told us they encouraged staff to feed back to them with any suggestions they had to improve the care provision. The registered manager told us they encouraged staff to undertake additional qualifications in order to improve their knowledge. Whilst informal learning was in place and staff were encouraged to upskill, the registered manager confirmed processes were primarily informal and due to this, learning was not always innovative or evidence driven and opportunities for improvement were not always identified. The registered manager gave examples of where they had involved families in people’s care and learnt about people through their relatives knowledge and experiences in order to improve outcomes for people. The registered manager told us that communication with relatives was positive and they involved relatives in people’s care through phoning them to provide updates.

A training matrix was in place which showed some gaps in staff mandatory training. The matrix showed not all staff had completed safeguarding training. This meant staff knowledge around some aspects of safeguarding processes was not always sufficient. The provider did not have action plans or improvement plans in place but we did see that some actions had been taken to make improvements at the home. However, the provider could not be assured all actions had been completed due to a lack of clear systems in place to address these improvements. Systems in place for analysis of accidents and incidents were minimal so processes to support learning from these were not always robust.