William Wood House, an extra care housing personal care service, was rated Requires Improvement overall following a focused inspection in April 2022, with breaches of Regulation 12 (safe care and treatment) and Regulation 17 (good governance) identified. Key failures included inadequate risk assessments, poor incident analysis, ineffective quality assurance audits, and medication management gaps, though the service demonstrated genuine caring practice and safe recruitment.
Concerns (6)
criticalCare planning: “one person who was diabetic did not have a diabetes risk assessment, in place. Although the care plan stated that the person was diabetic it did not include any information about what support the person needed”
critical
Record keeping
: “The folder containing the risk assessments and care plans for one person could not be found. This had not been reported to the management team so that it could be replaced”
criticalIncident learning: “Accidents and/incidents were not always analysed in a timely manner to see if any action needed to be taken to prevent a reoccurrence.”
criticalGovernance: “The providers quality assurance systems had not always been carried out effectively to identify areas for improvement. Not all of the registered managers audits had been completed each month.”
moderateMedication management: “One person had refused some of their medication on a regular basis, but action had not been taken to follow this up with their GP.”
moderateInfection control: “the guidance for testing staff (to test for five days) had not been followed when a member of staff had tested positive for Covid-19.”
Strengths
· Medicines were administered in a timely manner and in a way that respected people's preferences.
· Safe recruitment practices were being followed to ensure the right people were employed.
· Staff had completed training in the administration of medicines and been assessed as competent before administering medicines on their own.
· People told us they felt safe living at William Wood House and staff were described as caring and approachable.
· People were supported to maintain independence and were involved in planning their care.
Quality-Statement breakdown (10)
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Using medicines safelyRequires improvement
safe: Preventing and controlling infectionRequires improvement
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their care; Respecting and promoting people's privacy, dignity and independenceGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staff; Working in partnership with othersGood
William Wood House is a well-led extra care housing service rated overall Good, with a Requires Improvement rating for safe due to a medication error in which a person was without pain relief for four days and ongoing staffing pressures resulting in reliance on agency staff. The committed registered manager had implemented a detailed action plan addressing medicines management, staffing, and quality monitoring, with improvements underway but not yet fully embedded at the time of inspection.
Concerns (7)
criticalMedication management: “a person went without pain relief over a four day period. Staff had ordered the medicines but not acted in a timely and coordinated manner when they were not delivered on time.”
moderateStaffing levels: “staffing levels were variable. One relative said, 'I think the staffing levels are not good. They do use agency staff quite a lot to cover.'”
moderateIncident learning: “although the service had learnt from previous errors, there was still room for improvement to ensure people's safety.”
moderateGovernance: “Some routine management tasks and roles had not been completed recently...there had been a reduction in checks in the period leading up to our inspection, due to staffing issues.”
minorRecord keeping: “Staff recorded what support they provided each day, this was very task based so it was difficult to monitor changes over time.”
minorConsent / capacity: “in the isolated situations where people were starting to present with variable capacity, there was scope for a more formal review and recording of their capacity to consent to care.”
minorSupervision / appraisal: “there were good measures in place to provide supervision and team meetings and though these had not taken place with the usual frequency over the summer”
Strengths
· Manager was passionate, committed, visible and approachable, providing direct care during staffing shortages to ensure people's needs were met.
· Staff developed positive, trusting relationships with people and treated them with dignity and respect.
· Robust risk assessments were in place with personalised protocols tailored to individuals' circumstances.
· Effective recruitment processes including DBS checks and involvement of people using the service in staff selection.
· Strong complaints management with thorough investigation and proactive communication by the manager.
Quality-Statement breakdown (15)
safe: Medicines administration and managementRequires improvement
safe: Staffing levels and use of agency staffRequires improvement
safe: Risk assessment and safeguardingGood
safe: Safe recruitment practicesGood
effective: Staff training and competencyGood
effective: Supervision and staff supportGood
effective: Mental Capacity Act complianceGood
effective: Nutrition and health professional accessGood
William Wood House achieved Good ratings across all five key questions at its announced inspection in June 2015, demonstrating safe, personalised care with strong staff-resident relationships and responsive leadership. Minor governance gaps were identified around medicines error auditing and record availability, which the newly appointed manager was actively addressing.
Concerns (2)
moderateGovernance: “Where medicines errors had occurred, the audit and checks in place had not picked this up.”
minorRecord keeping: “The manager recognised the need to ensure the availability of information relating to the way the service was being provided...ensuring that important records...were available in the service's office.”
Strengths
· Care workers understood safeguarding responsibilities and knew how to report concerns including financial abuse.
· Sufficient staffing levels based on assessed needs, with flexibility to accommodate overruns.
· Positive, caring relationships between staff and people using the service, with dignity and privacy consistently respected.
· Personalised care plans tailored to individual needs, preferences, and levels of independence.
· Open culture with accessible manager, regular quality surveys, and responsive complaints handling.
caring: Dignity, respect and positive relationshipsGood
caring: Person-centred choice and autonomyGood
responsive: Personalised care planningGood
responsive: Complaints handlingGood
responsive: Record keeping and care plan reviewRequires improvement
well-led: Leadership and management cultureGood
well-led: Quality monitoring and governance systemsGood