Woodheyes

Updated 20 May 2021

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 Care Act 2014.

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

The inspection was carried out by one inspector 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.

Service and service type

Woodheyes is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service did not have a registered manager registered with the Care Quality Commission. This means that the provider was legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to 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 of this information to plan our inspection.

During the inspection

We spoke with five people who used the service and 10 relatives about their experience of the care provided. We spoke with 11 members of staff including the provider, manager, assistant manager, senior care workers, care workers, chef and housekeeping staff.

We reviewed a range of records. This included three people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records.

Updated 20 May 2021

About the service

Woodheyes is a residential care home providing personal care to older people with dementia and sensory needs at the time of inspection. Care was delivered over two floors in one adapted building, with passenger lift access. The service can support up to 38 people. At the time of our inspection there were 27 people living at the service.

People’s experience of using this service and what we found

Some quality assurance systems and processes in the service needed improvement. Not all audits were robust enough to identify shortfalls.

People’s needs and risks were not always fully assessed. We could not be assured people were supported to have maximum choice and control of their lives. Mental capacity assessments were not robust or detailed. This meant staff may not be able to support people in the least restrictive way possible and in their best interests; the policies and systems in the service needed improvement.

The number of staff on duty at times, and the lack of supervision were the only concerns staff highlighted for improvement.

People, relatives and staff were complimentary about the provider and manager, who had recently taken up their position. Staff noted improvements made at the service following our previous inspection, most notably infection prevention and control, where government guidance was now routinely followed.

People were supported to access healthcare services when required. People had access to their medication when they needed it, and medicines were managed safely. Minor concerns of medicine administration were noted.

People felt safe and protected from harm and abuse by staff who had been trained in safeguarding procedures. Staff were recruited safely.

People and relatives told us staff were caring and compassionate and were treated with respect. The service was welcoming, and there was a positive atmosphere. Complaints were investigated and people and relatives felt able to raise their concerns.

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

Rating at last inspection and update

The last rating for this service was inadequate (published 21 January 2021). The service has been in Special Measures since 21 January 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced focused inspection of this service on 29 October 2020. Breaches of legal requirements were found, and the service was placed in special measures. We imposed conditions on the providers registration. A director completed an action plan after the last inspection to show what they would do and by when to bring about the improvements needed.

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions safe and well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at were used to calculate the overall rating at this inspection. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

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 the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Woodheyes on our website at www.cqc.org.uk

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.