22 Woodlands Road

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.