Our response to the CQC report
CQC said: systems in place were not robust enough to identify concerns of risks and mitigate them and so:
We have reviewed our processes in respect of how records are monitored, and increased engagement with our staff team to ensure all concerns are communicated and acted upon promptly. The home now has a deputy manager to increase the home’s management oversight.
CQC said: Bed linen was found to be creased, unclean or stained.
We have changed the supplier of cleaning products and purchased new laundry equipment as well as linen. We have a hospitality manager in post who is now designated to looking at our high standards and has implemented daily checks on linen.
CQC said: people’s records did not always show care was delivered in line with the care plan and that there were areas in the care plan’s which required improvement in how risks were assessed and guidance provided to staff on how risks were mitigated. Whilst records were seen to be improved in relation to hydration, there were still times when people were being offered less than the target amount of fluid.
Our electronic care planning system allows regular checks to be performed throughout the day by the management team. At our daily team meetings, these records are reviewed and any individuals presenting concerns in respect of their fluid intake discussed and actions agreed. The team have undergone a number of training sessions to drive improvement in recording, there is a greater level of management oversight checking and reviewing records on a daily basis to ensure our records reflect the care delivered to our residents. All care plans have been fully reviewed, taking into consideration risks and the necessary actions required of staff to mitigate those risks.
CQC said: There were times when people did not receive their medications due to being asleep, too ill or out of stock. There was not consistent use of codes to show why medications had not been administered and no record of actions taken if people had not received their medicines for a period of time.
Medication management has been reviewed with the team, including the importance of ensuring reasons are explained for non-administration. We have revisited with our senior team the need to ensure that we work closely with our GP surgery for occasions where residents fail to have medication for more than three occasions.
CQC said: There were a programme of audits in place, however we saw audits which had not always picked up all of the shortfalls identified by stakeholders and us, and where shortfalls had been identified in the audits, they had not been addressed promptly.
Since our inspection, a new manager has been in post who has been made aware of the concerns including the issue with ensuring audits are robust and address any shortfalls in the service. Woodbridge Lodge has a robust action plan in place which supports the team to ensure that we continue to strive to improve the standard of our service to our residents.