Woodside Lodge

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

We assessed a total of 6 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was good. Our rating for this key question has deteriorated to inadequate. We found the provider was failing to meet their legal requirements and were in breach of four legal regulations. We identified significant and widespread concerns in respect of people’s safe care and treatment, safeguarding and staffing and fit and proper persons employed. The provider did not consistently protect people from abuse and improper treatment. They did not always share safeguarding information or make referrals in line with policy. Individual risks to people were not always assessed, and risks to people’s health and safety were not appropriately manage. The provider did not ensure they always acted to mitigate risks where concerns were identified. People’s medicines were not always safely managed, and the provider did not ensure people were supported by staff who had the relevant skills, knowledge and training to meet their needs. The providers recruitment practices were not in line with requirements to ensure they followed safe recruitment processes when new staff were employed.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Most people we observed seemed content in their environment. We received mixed feedback from people that they felt safe. For example, one person said “It’s very good here. I get on alright with the staff”, “I feel safe.”. However, another person we spoke with described “There are 2 wanderers here”. “They shout and scream and use bad language. I can’t hear the television”. “Sometimes they start undressing.” Feedback from relatives indicated they felt their loved ones received good care.

Staff we spoke with understood their safeguarding responsibilities and knew how to raise concerns with the leadership team.

We observed a person who was actively making attempts to leave the property and required support and redirection from staff. Staff interacted well with the person to try to alleviate their anxieties, however we reviewed care records and found no evidence that the provider had made required applications to restrict the persons freedom and liberty in line with their requirements.

We found significant shortfalls in the providers safeguarding processes. Systems for safeguarding people were not effective. We were not assured the provider always took action or consistently shared the required information with the local authority to ensure people were protected from the risk of harm. The providers safeguarding policy did not include details of which organisation staff should contact to escalate concerns such as the local authority safeguarding teams. We reviewed evidence that indicated some people were at risk of or experiencing harm and or abuse. Where we identified concerns of this nature we shared our concerns with the local authority. This included concerns around the management of people's diabetes and insulin administration and how some people’s overnight care was provided. We were not assured the provider consistently met their legal requirements where people were deprived of their liberty. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found examples where the provider failed to make the required application to the authorising body where they were unable to consent to their accommodation.

Relatives we spoke with were happy with the care their loved one received. For example, one relative told us they felt staff managed a recent health event well with their loved one and that they went on to improve without an admission to hospital. Most people we spoke with told us staff supported them to meet their needs and they had built good relationships with staff.

Staff and leaders could not always demonstrate they understood how to manage people’s individual risks. For example, where people had a diagnosis of diabetes, we asked a staff member what signs and symptoms they would look for to indicate if people’s sugars may be high or low and they were not clear. Some staff we spoke with had not reviewed risk assessments for people or were unclear what tasks had been assessed for people.

On the first day of the on-site visit, we observed prescribed thick and easy powder was accessible in peoples room. We raised this with the registered manager who confirmed this should be stored securely. The registered manager took action to address this. We observed staff support people to manage risks to their mobility and encourage people to use aids such as frames and wheelchairs. Staff gave people verbal prompts and instructions to support them to manage tasks.

We found significant shortfalls in people’s risk management. We were not assured people consistently received safe care and treatment. For example, risk management plans were not always in place, robust or contemporaneous to reflect the care people required. This included risks associated with thickened fluids being prepared and given, and inconsistent records and management of people's dietary needs to manage the risk of choking and dysphagia where they had a prescribed modified diet. There were no detailed care plans or risk assessments in place for people who had specific conditions. This included where people had diagnosis such as epilepsy, Parkinson's disease and hypertension. The provider failed to ensure people's diabetes was safely and appropriately managed in line with best practice guidance and delegated responsibility requirements. Shortfalls included not ensuring person centred plans were in place to identify individuals target blood glucose ranges, and steps staff should take if blood glucose readings went above these ranges. We were not assured the provider managed the risk of constipation and impaction where people were assessed to require support to manage their elimination. Records for people we reviewed identified people were assessed as high risk of constipation, however the provider failed to demonstrate action had been taken appropriately where records indicated people had not had a bowel motion for prolong periods.

Some relatives commented that facilities in the home needed to be improved. For example, one relative commented that the layout and space of the visiting room did not allow their loved one to use their walking aid which increased their risk of trips, slips and falls.

Staff and leaders were not always clear of their responsibilities in relation to compliance with health and safety requirements. For example, the maintenance staff delegated the task of assessing the window restrictors was not able to tell us what the requirements were. Where we found significant shortfalls in the management of legionnaire disease control measures, leaders of the service told us they were aware of the issues, however we found they had failed to take all appropriate actions.

We observed the provider had failed to ensure window restrictors were in place on a majority of the windows in areas of the home such as, bedrooms, bathrooms and communal areas at ground floor and first floor level. The registered manager told us that the maintenance staff had recently ensured all fitting were secured. However, we observed examples where wardrobes had not been appropriately fixed in place which placed people at the risk of injury. We observed areas of the home were used to store equipment and slings, including in the lounge and at top of the stair well. Areas of the home needed updating which the registered manager told us the provider was aware of.

We found significant and widespread shortfalls in the safe management of the environment. We were not assured the provider undertook appropriate measures to ensure people, staff and visitors accessing the building were appropriately protected. For example, the provider failed to meet their requirements to mitigate and manage the risk of legionella. Where the providers risk assessment dated 22 July 2021 showed several actions we required, we had no assurance that all the required actions had been completed. The provider also failed to ensure they appropriately reviewed, recorded and took action in response to hot and cold-water temperatures to protect people from the risk of harm of legionaries bacteria and the risk of scalding. We were not assured the provider took the necessary steps to protect people from the risk of fire. The provider’s fire risk assessment identified several actions that needed to be completed to ensure they appropriately protected people from the risk of harm. There was no evidence that the provider had rectified all the actions from risk assessments and we raised a referral to Hampshire & Isle of Wight Fire and Rescue Service due to our concerns.

People we spoke with told us staff were kind and caring. For example, one person said, "You only have to ask and if it’s possible they’ll do it for you.” However, they also commented staff were often 'busy'. Relatives we spoke with did not raise any concern regarding staffing, however one relative did comment they felt there had been some recent staff shortages which had meant they needed to relay information such as likes and dislikes to new staff.

Staff told us they felt there were enough staff on duty to meet people's needs and they received opportunities for training. Staff told us they felt confident they could seek advice and guidance, however staff we spoke with were unable to recall having had any or recent supervisions with leaders.

We observed staff were attentive to people's needs and responded timely to people's call bells during the on-site visits. We observed some positive interactions between staff and residents encouraging their interests and demonstrating patience and kindness.

We found significant shortfalls in the providers processes to ensure they met their requirements and provided safe and effective staffing. The provider could not demonstrate overnight staffing levels were sufficient to meet people's needs. We expressed concern that at the time of the assessment 6 people using the service required support from two staff to safely meet their needs. We reviewed records which identified people experienced a higher proportion of falls during the overnight period. We reviewed the providers dependency tool which did not include an assessment of people's needs overnight. Recruitment checks were not always carried out in line with requirements. We reviewed 3 staff records and found shortfalls in the providers recruitment process. This included where staff had worked in care previously, the provider failed to obtain satisfactory evidence of conduct in all relevant roles in line with their requirements. We reviewed the providers policy and found it did not include relevant information to ensure the providers recruitment process was robust. Staff had not received all training relevant to their role and we were not assured staff were always skilled and competent. For example, there was no training for staff, leaders and kitchen staff to ensure they were skilled and knowledgeable where people required a modified diet. There was no training for staff on choking and dysphagia where people were assessed to be at an increased risk. The provider failed to provide training for specific conditions such as Parkinson's disease and Epilepsy where they supported people with these conditions. Staff had not received appropriate training in fire and there was no record of up-to-date fire drills being undertaken at the service. Medicine training and competencies for staff were either out of date or not in place, this included staff who were administering medicines to people.

We received feedback from people and relatives that the home was generally observed as clean. One person told us, "Cleaners come in every day and make the bed and do the cleaning.” However, one relative commented, "Sometimes [there is] a terrible smell of urine." Relatives we spoke with told us they saw staff use PPE when supporting their loved ones to meet their needs.

Housekeeping staff understood their role and responsibilities regarding domestic duties. We spoke with the head of housekeeping who demonstrated they had a good understanding of infection control practices including ordering, storage and use of products and equipment.

On the first day of the on-site visit we noted areas of the home that were visibly dirty. This included a build-up of spider webs and dust in the main lounge lighting, excessive animal fur in the main office and areas of the home had a strong odour of urine. We also brought to the attention of the registered manager a window in a person's room which needed repair and had visible mould growth. On day two of the assessment we noted some improvements had been made to the cleanliness of the building from our previous observation in response to our feedback. We observed some staff including the leadership team did not always adhere to best practice guidance in relation to nail varnish and nail extensions. We raised our concerns with the registered manager and recommended they reviewed their IPC practices and audits to address this.

The providers policies and procedures for IPC were not always robust. For example, hand hygiene audits consistently recorded staff were not observed to follow 'bare below the elbows' and no actions were identified on what they had done to address this. The scope of the IPC audit for the home did not include all areas. For example, we observed a bath that had enamel erosion visible. The IPC audit did not include bathroom furniture which is in regular use. The providers policies were not always robust. For example, the policy for managing an infectious outbreak did not include information on acute respiratory infections and Covid-19 where this would be relevant. There were clear delegations of IPC tasks which were overseen by the head of housekeeping. We reviewed records which demonstrated regular cleaning schedules were undertaken. Staff had access to appropriate PPE and handwashing facilities or hand gel throughout the home.

A person we spoke with told us that there had been a significant delay when they came to the service in gaining their medicines. We reviewed records which confirmed this. We observed staff support a person to use an inhaler. The staff member did not ensure they followed best practice guidance when administering the medication which we raised with the registered manager on the on-site visit. Relatives we spoke with told us their loved ones received support with their medicines, however some relatives felt communication around any changes could be improved.

Staff were able to explain the process for ordering, returning and administering of people's medicines.

We found significant and widespread shortfalls in the management of people’s medicines. We found people did not always get the medicines they needed, people’s medicines records were not accurately maintained, and processes to ensure people received their medicines as intended were not robust. We found multiple examples of omissions in administration records, meaning we were not assured some people received their medicines as needed. We were not assured that all PRN ‘when required’ medicines were appropriately managed. For example, we were not assured that medication to alleviate signs of anxiety and distress were always appropriate where the provider failed to evidence how staff had explored least restrictive measures in the first instance. Care plans for peoples when required medicines were not in place, or where they were they did not provide sufficient information for staff on what steps they should take or what support should be offered prior to administration of medicines. Management of people’s-controlled medicines were not effective. We found concerns related to record keeping, storage and governance of controlled drugs. We raised serious concerns where we found staff were administering insulin to people without having required training and their competencies assessed in line with national guidance where this was administered as a delegated task. The registered manager was aware that staff were not up to date with the required training and competencies and failed to act timely to address the concerns.