Archived: Woodthorpe View Care Home

Updated 16 January 2020

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, to explore concerns received about safety and quality and to provide a rating for the service under the Care Act 2014.

Before our inspection, we reviewed information we held about the service. This included information received from local health and social care organisations and statutory notifications. A notification is information about important events, which the provider is required to send us by law, such as, allegations of abuse and serious injuries. We also contacted commissioners of the service and asked them for their views. We used this information to help us to plan the inspection.

We inspected the service on 11 and 18 July 2018. The inspection was unannounced. The inspection team consisted of three inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. During our inspection visit, we spoke with 13 people who lived at the home. We also spoke with three members of care staff, two members of the catering and domestic team, the quality manager and the registered manager. In addition, during the course of our inspection we spoke with one external health and social care professional.

To help us assess how people's care needs were being met we reviewed all, or part of, eight people's care records and other information, for example their risk assessments and medicines records. We also looked at five staff recruitment files, training records and a range of records relating to the running of the service.

We carried out general observations of care and support and looked at the interactions between staff and people who used the service. We also used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We did not request a Provider Information Return prior to this inspection. This is information we require providers to send us at least once annually to give some key information about the service, what they do well and improvements they plan to make. However, we gave the provider the opportunity to share this information during our inspection.

We asked the quality manager to send us a copy of the training record, meeting records and various policies and procedures. We received this prior to this report being completed.

Updated 16 January 2020

About the service: Woodthorpe View Care Home is a residential care home. It is registered to provide a service to older people. At the time of the inspection 15 people lived at the home.

People’s experience of using this service: The service was not safe. People were placed at risk of harm as risks associated with their care and support and the environment were not managed safely. Opportunities to learn from accidents had been missed which meant people had been exposed to the risk of avoidable harm. People were not protected from the risk of infection. There were not enough staff employed and safe recruitment practices were not followed. Although people told us they felt safe, a lack of leadership and systems meant there was a risk safeguarding issues may not be identified or addressed.

People were supported by staff who did not have the required skills or competency to provide safe and effective support. People’s health needs were not always met and their needs were not reassessed when their health changed. Care and support was not properly planned and coordinated when people moved between services. Care was not always delivered in line with current legislation and standards. People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible; the policies and systems in the service did not support this practice. The environment was not well maintained and this posed a risk to people’s safety.

People told us that staff were kind and caring. However, care plans lacked information about people which meant staff did not always have enough information to provide person centred care. There was an inconsistent approach to involving people in decisions about their care and support. People’s right to privacy was respected.

People did not consistently receive personalised care that met their needs. People were not provided with opportunity for meaningful activity. There was a risk that complaints and concerns may not be identified or addressed.

The provider had no oversight of the home and there was no management team in place. Consequently, there had been a failure to identify and address serious issues with the safety and quality of the service at Woodthorpe View. Systems to monitor and improve the quality of the service were not effective. Where audits had identified areas for improvement action had not been taken to address issues. The provider had not implemented learning from serious incidents. Failings in leadership and governance placed people at risk of harm.

Rating at last inspection: Requires Improvement (Report published on 15 August 2018). This service has been rated as Requires Improvement, or Inadequate, at our last four inspections. This demonstrates a failure to make and sustain improvements to the quality and safety of the service.

Why we inspected: This inspection was conducted due to concerns we received about the safety and quality of the service provided at Woodthorpe View Care Home.

Enforcement: You can see what action we told the provider to take at the back of the full version of the report. 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 continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

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.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

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.

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