Woodlands Lodge Care Home

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

Staff did not consistently protect people from abuse and improper treatment. They did not always identify allegations of abuse or make referrals in line with policy. Staff did not always assess risks to people's health and safety or mitigate them where identified. Risk assessments were incomplete and did not include risks we identified during our assessment. Systems to manage medicines safely were not effective. People did not always have care plans to guide safe practice. There were shortfalls in the safe recruitment of staff.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives expressed mixed views about the quality of care. Our assessment found elements of care did not meet the expected standards.

The registered manager had left the service two weeks prior to the assessment. The provider had put an interim management team in place. The interim management team told us that there had previously been issues within the service in relation to the quality of audits and information gathering that had taken place. The interim management team informed us that there was no analysis of accidents, and the team had started to look at how this process could be improved. Staff told us there had been several changes in the management team and they found this unsettling. Staff comments included, "Staff morale is so low; everyone is winging it, and when things go wrong, they blame others." Another said, "I love this place, but it is going downhill." The interim management team told us they were in the process of responding to the concerns raised by the local authority, staff, and relatives.

The service did not ensure lessons were learned when things went wrong and did not have systems in place to ensure reported safety concerns were addressed. The provider did not complete any analysis of accidents or incidents in order to learn from these events or identify necessary actions to improve safety. This limited the provider's ability to effectively manage the risks to people and meant people were put at increased risk of harm. 

People did not experience continuity of care. We observed where people were provided with special diets, there was no evidence of speech and language therapist (SALT) assessments or choking risk assessments in place. This meant we could not be assured people were provided with the correct food and drink consistency which increased the risk of choking. We found records of pressure care for people were not recorded consistently. This meant we could not be assured people had received pressure relief care as needed.

The interim management team told us people’s care plans were currently being transferred online from paper. Staff were not sure what records had been transferred over. or how to use the online system effectively.This showed there was a risk inaccurate information could be shared or directions from health care professionals not being followed.

Processes were in place to enable a smooth transition between services and to reduce the impact on people. However, the quality of people's care records and/or medication records required improvement to enable effective information sharing.

Processes were in place to enable a smooth transition between services and to reduce the impact on people. However, the quality of people's care records and/or medication records required improvement to enable effective information sharing and people’s plan of care was not always followed by staff. Putting people at potential risk.

Most people told us they felt safe. One person said, "I’ve deteriorated a lot since being  here." They told us they did not want to get out of bed because they had a number of falls and preferred to stay in their own room.Relatives spoken with felt their family member was safe. 

Staff told us they received training in safeguarding people and felt they had the skills to recognise and respond to concerns. However, we identified risks were not always managed effectively. We were not fully assured staff would recognise deterioration, which could mean people’s needs not being met and possible neglect.

We found risks were not managed effectively.People did not always have risk assessments and/or care plans in place for a specific health condition. We were not fully assured staff would recognise deterioration, which could mean people’s needs not being met and possible neglect. Appropriate measures were not in place to ensure people had regular and appropriate pressure care regimes in place to reduce their risk of pressure sores or contribute to the healing or recovery of pressure areas. The provider did not have sufficient oversight of people's mealtime experiences to ensure people were appropriately supported. The systems and processes in place to ensure staff used safe moving and transfer techniques required improvement.

The provider did not have effective oversight to identify and manage risks in relation to safeguarding people from abuse and improper treatment. Records showed staff had not always followed the provider’s policy for recording, reporting, and managing incidents and accidents. The service had policies and procedures in relation to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The service was aware of the need to and had submitted applications for people to assess and authorise that any restrictions in place were in the best interests of the person. However, we found people’s capacity assessments had not always been completed or there was conflicting information within their assessments.

Some people’s risks had not been effectively assessed and measures put in place to manage those risks.We found that some people were having to wait for extended periods of time for their care needs to be met. We found the service did not meet people's needs safely in relation to medication management, infection prevention and control and did not ensure that care records were accurate. This placed people at risk of avoidable harm.

There was a failure by senior staff to ensure all risks to people were considered or shared. Care staff told us they were not involved in assessing risks to people. Staff had not received training for managing people’s needs when they became distressed. This meant there was a risk that people’s risks associated with periods of distress were not managed consistently and effectively. Some staff were not always aware of people’s individual risks and how these were managed. For example, where people were on modified diets staff did not know if people were at risk of choking or had a SALT assessment in place. One staff member said they had not read the care plans. This placed people at increased risk of potential harm.

We observed the mealtime experience at the service. Some people were unable to eat as they required assistance, and there were not enough staff to support them. So, people had to wait until a staff member was available. During lunch we observed a member of staff supporting a person to eat. The person was person was constantly sliding over to one side which would have made it more difficult for them to eat and digest their food. The staff member asked senior staff for assistance to make the person more comfortable but no action was taken.We observed people sat in the communal corridors blocking fire exits and we found areas of the building were untidy, cluttered and in need of cleaningputting people at potential risk.

The provider had not ensured each person’s risks had been effectively assessed and measures in place to manage those risks. Some people had conflicting information within their risk assessments, which put them at risk of not being supported safely. People did not always have risk assessments and/or care plans in place for a specific health condition. Appropriate measures were not in place to ensure people had regular and appropriate pressure care regimes in place to reduce their risk of pressure sores or contribute to the healing or recovery of pressure areas. The provider did not have sufficient oversight of people's mealtime experiences to ensure people were appropriately supported. The systems and processes in place to ensure staff used safe moving and transfer techniques required improvement.

People were not cared for in a safe enviroment designed to meet their needs.

The management team were aware of environmental issues that needed to be addressed.

The service required a deep clean, and many areas were poorly maintained, making cleaning difficult, and storerooms were extremely untidy and disorganised. Equipment was not stored safely.We found some equipment required cleaning. For example, shower chairs were rusty so staff were unable to clean them effectively.Emergency systems were not robust.

The service failed to effectively identify or monitor environmental risks, which increased risks to people's safety. We found a lot of the checks that were in place were not robust. They weren’t clear on what safety checks were being carried out and didn’t assure us that they had a clear oversight of the safety of the environment and this was confirmed through observations we found on the day.The service did not protect people from burn risks. We discovered several uncovered radiators throughout the facility. Fire safety procedures were not always implemented. We found issues which posed a risk to people using the service which had not been identified or addressed to ensure people lived in a safe environment. The service did not adequately protect people from the risk of fire. We found people had personal evacuation plans (PEEPs) in place, however, these did not contain key information such as where people’s bedrooms were located and pictures of people, so that people could be easily identifiable in case of a fire. An updated fire risk assessment was not in place. We found fire doors propped open and fire exits blocked. The managers walkaround had failed to identify and adress any of these concerns.The provider had not ensured equipment used to deliver care was used properly or in good working order. For example, we found hoists were broken and in need of repair.There were a range of environmental checks in place but these had not been completed consistently.

Feedback from people and their relatives was mixed in relation to staffing. Most people we spoke told us that staff were kind and caring, however some people told us that there were insufficient staffing levels to meet their needs. One person said, "No, they’re short staffed here, they said it themselves [the staff].”Another person said, “Theres insufficient staff in the morning and over lunch time” they went on to say, “ I have to wait for assistance to go to the toilet and I sometimes wait three quarters of an hour, and they just can’t get here in time, but they’re [staff] very good about it”.

Staff told us there were not always enough staff on duty to meet people’s needs.

During the inspection there was not an appropriate staffing level and skill mix to make sure people received consistently safe care that met their needs. Throughout our visit, staff were busy with care tasks. Staff had very few opportunities to spend any meaningful time with people or ensure their safety. There were times when people at risk of falls were left unattended for long periods of time by staff. This meant there was an increased risk of falls. During lunchtime, people who needed encouragement and prompting with their meals were not receiving this as staff were too busy.

Staffing levels were insufficient to meet the needs of people using the service at busy times, governance and auditing processes in place had failed to identify and rectify this. Staff training was not completed at a satisfactory level across the service and the service did not have a process in place to monitor the frequency and quality of staff competency checks across the service. The service's recruitment processes were unsafe. Recruitment checks were completed, however there were discrepancies and gaps in the staff records. For example, we saw gaps in staff's employment history were not always fully explored and staff files did not contain evidence of an interview or induction taking place.

People were not protected as much as possible from the risk of infection because premises and equipment were not kept clean and hygienic.

The management team told us they were aware of concerns regarding the cleanliness of the home and were working towards improving these standards.

There were strong malodours in areas of the service. The service required a deep clean and many areas were poorly maintained, making cleaning difficult, and storerooms were extremely untidy and disorganised. Kitchenettes were damaged and broken with engrained dirt which was not possible to clean. We saw personal protective equipment (PPE) was not stored appropriately. Some armchairs were dirty and in need of a deep clean. These practices increased the risk of cross infection.

The systems used by the provider to monitor infection, prevention and control practice were not effective in practice and did not ensure people were always protected from the risk of infection. There had been a lack of oversight from the management team and audits in place to monitor infection prevention and control had not identified the concerns we found during our assessment.

People told us they were happy with the support they received to receive their medicines. One person told us, “Oh yes, they [staff] come round with my tablets regular”. Another person said, “They bring them in the morning [medications], then at teatime and then at bedtime.“ However, our assessment found elements of care did not meet the expected standards.

There was conflicting information as to which staff administering medicines had been assessed as competent.

Medicines were not always managed safely which placed people at risk of harm. The provider had failed to ensure staff had received all necessary training and had not checked the competency of all staff who were administering medicines.Medicine Administration Records (MAR) did not always record people’s allergies or include photographs of residents to reduce the risk of a medicine being given to the wrong person.This was particularly important because of the high use of agency staff.The records made in the controlled drug register did not always follow legislation or good practice guidance. The system in place to ensure medicines were always stored safely was ineffective in practice. People’s PRN ('when required') protocols required further guidance to ensure these were given at the times they needed them. When some PRN medicines were administered the effectiveness was not always assessed or it was not assessed and recorded in a timely manner.