22 Woodlands Road

Updated 18 November 2023

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.

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

22 Woodlands Road is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. 22 Woodlands Road is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

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.

At the time of our inspection there was not a registered manager in post. The provider had recruited a manager. However, they had not registered with the Care Quality Commission.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority 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 observed the interactions between staff and 3 people who use the service. We spoke to 2 people and 3 relatives about their experience of the care provided. We spoke with 8 members of staff, including the operations manager, home manager and care workers. We observed staff interactions with people whilst delivering care and support in communal areas.

We reviewed a range of records. This included 3 people’s care records, 3 medicine records and daily notes. We looked at 3 files in relation to the recruitment and supervision of staff. We examined a variety of records relating to the management of the service, including policies and procedures, quality assurance audits, and health and safety records.

Updated 18 November 2023

About the service

22 Woodlands Road is a care home providing accommodation and personal care to people with a learning disability and/or autistic people. The home has communal lounges, a dining room and a kitchen. Bedrooms were set over 2 floors. The home is registered to support up to 3 younger adults. At the time of inspection, the service was supporting 3 people.

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

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.

Right Support:

People were mostly supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, we made a recommendation about capacity assessments and capacity records.

Care plans did not always contain correct, up to date factual information. We found incorrect and missing information within the care plans. However, staff and relatives told us that staff knew people well. Communication needs were not always reflective of people’s current needs.

People’s health needs were not always recorded. We found missing information regarding people’s health and health results. However, we found no evidence of harm. People had a hospital passport and were referred to healthcare professionals as required.

Environmental risks had mostly been assessed and mitigated. The home had window restrictors and staff checked hot water temperature to protect people from scalding. The provider already had an action plan in place to update the environment to ensure the home decoration was person centred.

There was adequate staffing to meet people needs. Staff were safely recruited; staff received an induction and training before lone working. Staff felt supported within their roles.

Right Care:

People were put at increased risks from fire. During the inspection we found fire risks that had not been mitigated. Not all known risks had been recorded and mitigated. When mitigating strategies had been recorded, these were not always kept up to date and at times contained incorrect information.

Medicines required improvement. When ‘As required’ medicine was administered records were not consistently completed to evidence the reason or outcome of the medicine being given. Records of people’s distress were not consistently completed.

People were supported by staff who knew them well. Relatives told us and we observed staff respected people and treated them with dignity and compassion. People were supported to maintain their privacy and promoted their independence.

Safeguarding policies and procedures were in place and staff knew how to report any concerns. Staff received training in safeguarding adults. The provider had engaged and notified the relevant partners when an incident occurred.

Right Culture:

Systems and processes did not always effectively ensure good oversight of the service. Audits had not always identified the areas that required improving found on inspection. The manager supported people who used the service and therefore, did not always have the time to complete the necessary relevant audits to review information recorded and ensure records were kept up to date and factual.

Complaints procedures were in place. Staff and relatives told us they knew how to complain, and any complaints had been addressed and rectified.

The provider asked for feedback on the service delivered. Staff and relatives were given an opportunity to complete a survey to raise any concerns or improvements required as well as to identify areas of good practice.

Staff felt supported within their roles. Relatives knew the manager and felt able to raise any concerns, issues or niggles. Staff were kept up to date on changes within the service and relatives were kept updated on any changes or incidents that occurred with their loved one.

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

Rating at last inspection

The last rating for the service under the previous provider was good (published 29 September 2019).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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 that 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 22 Woodlands Road on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to risk management, medicines and management oversight at this inspection.

We have recommended the provider review people's mental capacity assessments.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.