Woodham Lodge

Updated 5 January 2024

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.

Inspection team

An inspector and 1 Expert by Experience carried out the inspection. 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

Woodham Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement dependent on their registration with us. Woodham Lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. The service had a manager registered with the Care Quality Commission.

Notice of inspection

This inspection was unannounced.

What we did before inspection

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 the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spent time with all the people who use the service. We spoke with 2 people who used the service who were able to speak with us and 3 relatives about their experience of the care provided. We also spoke with 4 members of staff including the registered manager and support workers.

We reviewed a range of records. This included 3 people’s care and 6 medication records. We looked at 1 new starter staff file in relation to recruitment. A variety of records relating to the management of the service, including risk assessments and procedures were reviewed. We also carried out a visual inspection of the premises.

After the inspection

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

Updated 5 January 2024

About the service

Woodham Lodge is a residential care home providing support to 6 people at the time of the inspection. The service can support up to 6 people. The service comprises of one purpose-built bungalow.

We expect health and social care providers to guarantee people with a learning disability and autistic people ; respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

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

Right Support

Care plans and monitoring records were not always in place for people to support them with their physical health needs.

The service didn't support people to have the maximum possible choice, control to be independent over their own lives. Aspects of peoples lives such as sharing a bedroom were not recorded or discussed as part of a decision-making process.

We have made a recommendation regarding recording decision making.

People were encouraged to set targets and achieve goals in some areas of life for example, planning a holiday and building relationships and contact with family members. However, this wasn’t consistent.

The service didn't always support people in a safe, clean, well equipped, well-furnished, and well-maintained environment. Due to a kitchen refurbishment people were exposed to unplanned risks as well as infection prevention and control issues. Regular fire drills were recorded as taking place however, there were some issues with people’s personal evacuation plans as the kitchen refurbishment disruptions hadn’t accounted for these risks.

Medicines were managed and administered safely. However, cleanliness of storage needed to be improved. Records and systems to monitor medicines were in place. Staffs’ competencies to administer medicines was checked. People were supported with their medicines in a way that promoted their independence and achieved the best possible health outcome.

Right care

The service acted to protect people from poor care. Staff knew how to report any concerns to the appropriate places. Staff had training on how to recognise and report abuse.

The service had enough staff to meet people's needs and keep them safe. However, some staff training was not up to date or completed.

We have made a recommendation about staff training.

People were supported by person centred practices; however, some support plans were more personalised than others and this wasn’t consistent. People were encouraged to take positive risks. Risk assessments were in place for most people. However, there were some gaps.

We have made a recommendation about care plans.

Right culture

People were supported to lead inclusive and empowered lives and make choices with the support of advocates where needed. However, some choices were not documented appropriately. The quality assurance processes in place were not always effective in identifying and addressing shortfalls in a timely manner.

Safe recruitment processes were followed. People and those important to them, were involved in planning their support. The service enabled people where appropriate to work with staff to develop the service. Staff felt supported by the manager.

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

Rating at the last inspection and update

The last rating for the service was good, published on 1 November 2017.

Why we inspected

This inspection was prompted by a review of the information we held about this service and due to the length of time since the previous inspection. 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. This is based on the findings at this inspection.

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

Enforcement

We have identified breaches in relation to assessing and managing risks, premises, records, infection control, safe care and treatment, and manager oversight at this inspection.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.