Woodroffe Benton House

During an assessment under our new approach

Date of Assessment: 10 March to 19 March 2025. Woodroffe Benton House is a residential care home providing support to older people and people living with dementia. We inspected the service to follow up on previous concerns relating to safeguarding and deprivation of liberty safeguards (DoLS), medicine management and the overall governance of the service. We reviewed quality statements under the safe, caring and well-led key questions. Improvements had been made, and the provider was no longer in breach of regulations. The registered manager has implemented new quality assurance processes which had improved practices and learning in response to safety incidents and the overall running of the service. Safeguarding concerns were now recognised and reported to the local authority, the registered manager and staff now had oversight of people’s DoLS authorisations to ensure imposed conditions were met. Medicine audits were now undertaken. The provider changed their medicine management system to ensure people received their medicines safely. Staff were recruited safely and received appropriate training and supervision. Staff told us they now felt valued, and their well-being was considered. There were enough staff to respond to people’s individual needs. People’s bedrooms and communal spaces were clean. The registered manager had plans to improve the environment, however, interim measures were in place to ensure the service was appropriate for people living with dementia. People and their relatives told us they were happy with the service, and they were now involved with reviews of their care and had opportunities to provide feedback. People were engaged with the programme of activities and could use the onsite café to meet their friends and families. The registered manager looked for opportunities to continually improve the standard of care and environment. Staff were able to raise concerns; they told us managers were approachable and supportive.

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During an assessment under our new approach

Date of assessment, site visits took place on 22 Aug, 27 Aug, and 05 Sept 2024, off site assessment activity ended on 18 Sept 2024. We assessed this service due to medicine management concerns, this is their first assessment, as a result we undertook an assessment of all quality statements.

The registered manager oversaw Woodroffe Benton House and another of the provider’s services. They told us of quality assurance processes they had planned to embed but had not yet implemented. Systems did not always instil good practices and learning in response to safety incidents. Some incidents of unexplained bruises to people had not been fully investigated and referred to the local authority safeguarding team.

Medicine audits were undertaken, however, action taken in response to concerns were not robust enough to mitigate reoccurrence and reduce errors. Audits did not identify the additional concerns found during our assessment. Staff were recruited safely and mostly received appropriate training and supervision, however, staff who administered medicines had not all been assessed as competent to safely use the newly introduced medicine system.

People told us they were happy with the support they received; however, they were not involved with reviews of their care and did not have the opportunity to provide feedback about the service. People were engaged with the programme of activities and could welcome visitors at times to suit them and could use areas of the service or the onsite café to meet their friends and families.

We found breaches of regulation in respect of safe care and treatment, safeguarding and governance. You can find more details of our concerns in the safe and well-led findings below.

In instances where CQC have decided to take civil or criminal enforcement action against the provider, we will publish this information on our website after any representations and /or appeals have been concluded.

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