- Staffing issues were reported regarding not enough staff, especially at nights. The dependency tool was not completed properly between December 2018 and June 2019. - Documentation issues were found, such as care plans not being reviewed since December 2018 and risk assessments not being reviewed. Daily logs were not properly documenting important information. - Falls monitoring and risk assessments were not always being updated after residents experienced falls. Observation records were also not always being updated.

1. Concerns Progress Risk
Staffingissues.Notenoughstaff onnights.Allegationsof high
numberof highdependencyresidentsandstaff notbeingable to
answercall alarms.
Dependencytool wasn’tcompletedbetweenDecember2018
and June 2019.
The newtool completedinJune 2019 (attached) indicated
that Woodlands were overstaffed.
Nightswere anissue andagencyhad to be sought,butnow
nightsare overstaffed –as evidencedonthe attachedrota.
Aliciainterviewedstaff membersandone indicatedthere
were notenoughstaff onthe EMI unit(currentlyhas2 staff).I
explainedthe dependencytool showedtheywere over
staffedandthat only2 residentshadbeenhighlightedashigh
dependency.The staff memberexplainedall residentsinthe
EMI unitwere double handlersandshe consideredthemas
highdependency.Aliciatocheckwith Jill the accuracyof this
information.Thisstaff memberalsomentionedworkingover
100 hoursina 2 weekperiodwhichpointstowardsbeing
understaffed.She hadbeenpickingupa lotof shifts. After
speakingtoJill,the carerhad pickedupextrashiftsdue to
sicknessandannual leave.
26.7.19 Jill hashad a supervisionwiththe carerinquestion
and has clarifiedthatshe pickedupextrashiftsthroughher
ownchoice.Carer alsohasn’tsignedanopt in/out 48 hr week.
Thiswill be done whenshe isbackfrom holiday.Also, Jill
askedabouther viewof all the EMI residentsneedingtobe
classedashigh risktherefore more staff are required.Carer
statedit washer opinionanddidn’ttake intoaccountother
factors.Some EMI residentsneedthe helpof 2carers for
personal care but are independentinotherways.Carer
understoodthisandapologised.She alsomentioned
unwitnessedfallsandthe carerhas admittedto exaggerating.
9.8.19 132 hoursper day ondependencynowandthe home is
deliveringmore thanneeded.Evidenceddependencyand
rotas. Nightsmostlystaffed.A couple of occasion’s agencyhas

2. beensought.More difficultatthe momentdue toschool
holidays. Residential1seniorand2 carers duringthe day.
NewUnit2 seniors2 carers.EMI 1 senior,1 carer.Lookingto
move some staff overto EMI now dependencyhaschanged.
Staff were presentwhenIenteredthe home.Noconcerns.
23.9.19 Dependencytool rechecked.All ok.
Residentsnotreceivingsufficientpersonal care.Residentsare
unkemptwearingotherresidentsclothingwhichare oftenstained.
At a visiton11.7.19 by AliciaGasstonarrivingat8.00am, all
residentswere dressedappropriatelyandappearedclean.
Some residentswere still inbed(asistheirright),some were
inthe lounges/corridorsandsome were inthe diningroom
waitingforbreakfast.Resident’s hands/fingernailsappeared
cleanand nostainingtoclothingwasseen.
Jill andSharonwill startto logthe dailywalkroundfromtoday
(11.7.19) and will note anyissuesfound. Aliciatocheck
progressonfuture visits.
26.7.19 Dailywalkroundisnow beingdone everyday.It’s
loggedandissues are dealtwithanddocumented.Nogaps
and Jill/Sharonare findingextrathingstoaddto it.
23.8.19 More auditsto be addedto folderforSG meeting.
Hygiene –hands notwashedaftermeals. Each unithas wetwipesthatare usedaftereachmeal. Jill isto
implementanextracolumnonthe foodand nutritionchart
witha box to tick whenhandshave beenwashed.Thiswill be
discussedinstaff meetingsandsupervisions.
26.7.19 Newcolumnhasbeenaddedto observation chartand
carers signwhentheyhave washeda resident’s hand.
EvidencedasignedsheetforJuly.
23.8.19 to be addedto folder.
The home has an unpleasantodour. At a visiton11.7.19 by AliciaGasstonarrivingat8.00am and
there wasno odourpresentat all withinthe home.There was
strongair freshenerbutmorningroutinesiswhensmellsare
stronger. There wasno hintof a urine orfaecessmell.
The lounge anddiningareashave had the flooringreplaced
due to carpet cleaningnotworkingtosatisfaction.The flooris

3. nownon slipflooringwhere spillscanbe moppedup
sufficiently.
Update:at around5pm AliciaGasstonconductedanother
walkroundand as youenterthe EMI corridor,there wasa
urine odourconcentratedaroundone area.
26.7.19 Carpetcleanercouldn’tgetpipesinthe building.The
domesticstaff have cleaneditand there’snoodour.Aliciato
checkon walkround.Newmanagerhas planstotackle the
EMI unitenvironment.
9.8.19 Dennishaswalkedroundthismorningandthere was
no odour.Carpetisbeingremovedinthe lounge.Being
decorated.Magnoliaandhandrailsare goingto be red.Dining
room to be done,notas a priority. Noodouron walk round.
23.8.19 Noodour.
Attitude of staff ispoor,not encouragingresidentswithmeals. Jill hasobservedstaff atmeal timesandcouldn’twitnessany
poor attitudes.OnAliciaGasston’svisiton11.7.19, breakfast
was observedandoverheardfromthe officeandnopoor
practice was noted.
Encouragementwill be addressedinteammeetingsand
supervisionsasa standingagendaitem.
A lotof positive interactionsbetweenstaff andresidentswere
observed.Aliciachattedwithsome of the residentsandall
had saidthe care is brilliantandthe girlsreallyhelpthem.
Whenurgenthelpisrequired,theymentionedthey’venever
had to waitfor a response,evenwhenit’sclearthe girlsare
busy.Theyenjoythe food.
26.7.19 Menuchoice is good – 3 weekrollingmenu.A new
mealtime observationaudithasbeen putinplace and1 audit
a monthwill be completedrotatingthe units.Itlooksat
environment,meal choice,equipment,cleanlinessetc.
Evidenced.Inthe diningroom, residents’ plateswerealready
emptyandtheywere awaitingpudding.
23.8.19 Nextauditisdue.

4. Issuesaroundweights –residentsare visiblylosingweight. All 3 unitsweightchartschecked.Mostresidentresidents
have gainedormaintained.Some residentshighlightedas
losingweightandnoreferral todieticianmade.Issuesaround
communicationwithGPwhenGP’shave beenattendingfor
anotherissue andweightshave beenmentioned,they’ve said
to keepmonitoringbutthishasn’tbeendocumented.AL,KG
and EA have all beenreferredtodaydue to significantweight
loss.Phone calls/referralswill be documentedinthe care
plansand anyone withweightlosseswill be movedtoweekly
weighinsandautomaticallyreferredtoDietician.
26.7.19 Residentshave beenreferred. Annettehasbeeninall
weekandshe’sauditedthe weights.Everythingisbeing done
as should.Uponchecking,Aliciaidentifiedsome weights
weren’tbeingdone weeklyastheyshould,lastbeingweighed
13.7.19. Jill/Sharon hasaskedthe care staff to ensure these
weightsare done today.Aliciatocheckbefore leavingoron
nextvisitthatthishas beendone.
9.8.19 Weightsare still beingdone whentheyshouldwiththe
exceptionof acouple.Advisedto documentif the residenthas
refusedratherthanleave blank.Will continue tocheckat
future visits.
23.8.19 EvidencedEMIweightswhichare done weekly.All
complete andupto date.
Staff on shiftcongregate outsidesmokingleavingresidents
unattended.
Breaksaren’tset– it dependsonsituationatthe time.In
essence,1fromeach unitcouldbe outside togetherwill
domesticstaff.Theyhave beenaskedtosmoke inthe
designatedareaatthe back of the buildingoutof sight – this
will be emphasisedinstaff meetings. Unitsare neverleft
unmannedalthoughloungeareasmaybe unattendedattimes
(whenstaff are assistingotherresidentsintoilets,showers,
respondingtoalarms etc.).
26.7.19 Jill tosenda memoto staff regardingsmoke breaks
and makingsure theyare round the back and notat the front

5. of the building.Thiswasdiscussedinateammeetingbut
wasn’tminuted.Itwasmissedoff.
9.8.19 On all of my previousvisitsIhave notwitnessedany
staff outside smokingorcongregating. NFA.
Staff document‘Refused’duringmedicationroundsratherthanleave
it a shortwhile before attemptingtogive medsagainwith
encouragement.
AliciaGasstonlookedatMAR charts on hervisiton11.7.19.
There were instancesof residentsrefusingandthiswas
documentedonthe backof the MAR chart. I askedthe senior
whatshe didif someone refusedandshe statedshe would
waittill the endof the roundand try again.
It was clearthat if medicationwasmissed,staff weren’t
confirmingwitheitherGPor pharmacywhethermissed
medicationwouldhave anadverse reaction. Jillistoensure
that staff checkwitheitherGPor pharmacy whenmedication
ismissedanddocumentitinthe dailylogs andMAR. WhenJill
workedat Woodlandspreviously,she conductedamedsaudit
monthly.Thisisto be reintroduced –the auditwill lookfor
errorson MAR’s and documentation,stockcountsand
observationswill be done tocheckstaff competency.
26.7.19 GP contactedabout missedmedsandtheyhave
advisedtocontact themafter3 daysof missedmeds.Ihave
advisedtoensure itisinthe policysoitclosesthe loopand
coversthem.Medswere alsodiscussedinastaff meeting
whichhas beenminuted,
Bootschemistare wantingto supplymedsinboxesbutthis
won’tbe appropriate so McGill’sare Woodlands new
pharmacy, Boots have statedthe nextmonthwill be supplied
as normal before transferringtoMcGill’s.
9.8.19 Changingto McGill on 16.9.19. Lynnhas starteda meds
audit(newunit).Will feedbackfindingswhenauditis
complete.
23.8.19 1 medstrolleyaudited,other2to be done.Also,
where auditshave happened,make sure actionsfromissues
foundare documented.

6. Incorrectmovingandhandlingprocesseswitnessedincludingadrag
lift.
Jill hasseennoevidence of this.She hasdone walkrounds
and sat inlounges etc.observingstaff andherfindingsare
that staff are usingthe correct techniquesanddoingsosafely.
On AliciaGasston'svisiton11.7.19, a man had a fall just
outside the office.A familymemberwasassistinghimtoa
chair and due to an injuredarm,she couldn’tkeepholdof him
and he fell tothe ground from a standingposition.The
residenthithishead(cornerof eyebrowandcheekbone)
whichwasbleeding.Staff reactedquicklyandefficiently
establishingwhetherthere were anyotherinjuries(the
residentliftedhislegshighoff the groundwithhiships
withoutbeinginstructedandalsostretchedhisarmsout) and
he wantedto getup. 2 membersof staff managedto slide a
slingunderneathhim usingthe roll techniqueandliftedhimto
a chair. A coldcompresswasusedon hisheadinjurytostem
the bleedingandatemporarydressingwasapplied.The
seniorcalledthe DistrictNursingTeamwhovisitedanddida
properdressingandcheckedhimover.The GP wasalsocalled
whoadvisedobservations.Ataround5.45pm,I lookedatthe
residentscare planandthe fall had beendocumentedinthe
dailylogs,medical professional logs,afallsreporthadbeen
completedandabody map.
26.7.19 Trainingmatrix iscomplete withM&Hincluded.4
membersof staff are still waitingtodoM&H trainingandthis
will be done nextweek.
9.8.19 Viewedtrainingmatrix.Those withgapsagainstall
trainingare eithernotworkingoron maternity.All other
trainingismore or lessupto date.No furtherconcerns.
There isno registeredmanageratthe home.Anoperationsmanager
has beensenttosupportthe home but isn’tDBS checked.
Jill evidencedherDBScertificate dated1.7.19.
A managerhas beenrecruitedandstarts5.8.19. She iscoming
froma Voyage care home andis a registerednurse witha
currentpin. She is alsoregisteredwith CQC.
23.9.19 Lynne Sylvesterisinpost.Lookingtoregisterwith

7. CQC.
The falsifyingof documentationisalleged. Evidence wasseenona visitthere wasnodocumentationand
on theirnextvisititwasthere.Itissuspecteditwas
completedretrospectively.OnAliciaGasston’svisiton
11.7.19, some weightchartsappearedtohave been
completedinone go(all the same writing,same penandno
signatures). Jill informedme the workerlikelyforgottosign
and it'sthe persononshiftdoingthe weights. Jill tocomplete
auditsto determine if falsificationishappening.
26.7.19 Jill hasn’tmanagedtocomplete thisauditasyet.Will
be conductingnextweek.
9.8.19 Jill hasfoundthisdifficulttocheckasif somethingis
documentedithardto determine if thishasbeendone
retrospectively.
On a previousvisit,Iwitnessedafall andlaterinthe dayI
askedforthe gentleman’scare planandeverythingwas
documentedasitshouldhave been.Asthisisunable tobe
checked,Iam signingitoff as green.If anyother issuestolight
viasocial workers thenwe can re-visit.
Care Planreviewsare notbeingcompletedsince December2018. Risk
Assessmentsnotreviewed.
A ladynamedJolene isworkingoncare plans andrisk
assessments atpresent.Theyaren’tthe bestbutprogressis
beingmade.Thisisa time consumingtaskandwill be checked
on regularlyatfuture visits. Marie hasfedbackthat Jolene’s
care plansare some of the bestshe’sseen.
26.7.19 Jolene hasagreedtowork3 daysper weekonthe
care plans. Annette hasbeenintoreviewcare plans. Marie
Cookis visiting6.8.19.Care planauditidentifiedwhichwillbe
usedgoingforward.
9.8.19 Care plansamendedslightlyandindex infrontof files
now. Marie visitedandstayedapprox.30minsand washappy
withthe index. Jolene isgoingtoconductthe care planaudit.
23.8.19 Care plan auditsare veryin depthand thorough.

8. Jolene hasbeencompletingthese.Newunitisalmost
complete.AdvisedtobringJScare plan(withconsent) to
evidence thatconcernsonthe audithave beenaddressedin
the care plan.
ReasonsforGP visitsnotbeingdocumented. AdultSocial Care have seenevidence thatGP’shave visited
but haven’tdocumentedthe reasonfortheirvisits.Norisit
documentedinthe dailylogsthe reasonforcallingaGP out.
Thisis goingto be addressedatthe senior’s teammeeting.
26.7.19 Thiswas discussedinstaff meeting(evidenced).Will
checkprogressat everyvisit. BTcare file evidencedGP
contact, reasonandvisit.Alsorelativeslogwhere staff have
phonedfamilytoupdate of contactwithGP and outcome.
Issueswiththe completionof dailylogs, Logs are aboutwhat staff have done forresidentsandnothing
aboutresident’s chats,wishesorpreferences.Issueswith
loggingimportantinformationsuchaswhena residentis
takenintohospital.
Dailylogsare goingto be addressedinteammeetingsand
supervisionsand Jill istoaskMarie Cook to conduct dailylogs
training. Jolene tobe invited.
26.7.19 Marie isdue to visittodo trainingondailylogs.Logs
were highlightedinthe staff meeting(evidenced)regardingit
beinglegible,usingblackink, notusingabbreviations andin
the front of the handoverfolderitstateshowtolog sleeping
and enforcesthe above.
9.8.19 Marie Cook has visitedandishappywiththe logs.
Jolene tochecka sample.
23.8.19 Aliciatoseekguidance from Marie aboutdailylogs
and training.
Fallsmonitoring.RiskAssessmentsnotupdatedwhenresidentshave
falls.Norobservationrecords.
FallsmonitoringauditwasevidencedatAlicia’svisiton
11.7.19. Noanalysistobe done as no patterndetermined.A
memberof staff Aliciainterviewedhasstatedthatthere are a
lotof unwitnessedfallsonthe EMI unitand itwouldbenefit
havinganothermemberof staff onthe unit.More workneeds

9. to be done on fallspreventionandmonitoring.
26.7.19 Staff that made commentshasadmittedto
exaggeratingthe amountof unwitnessedfallsinsupervision.
Sensormattsand crash mats are all insitu. Bedrailsused
whennecessary.
Jolene workingonupdatingthe riskassessmentswhen
residentshave falls.Tobe checkedonanothervisitwhen
Jolene hasupdatedmore care plans.
9.8.19 Jolene hascompletedherfirstweekof 3 dayson care
planningandriskassessments.Will checkwhenmore
progresshasbeenmade.
23.8.19 Jolene onleave sounable tocheckprogress.Visitto
be arranged when Jolene isback.
Sensoralarmsnot presentwhencare planned. AdultSocial Care have seenevidence thatsensoralarms
weren’tpresentwhentheyshouldbe. Jill/Sharontoidentify
all residentswithsensoralarmsandensure they’re present.
26.7.19 Jill toimplementanotheractionontodailywalkround
to ensure residentswithsensoralarmshave them.
9.8.19 Lynn has beentaskedwithdoingacheckof the sensor
alarmsto see if they’re required,whethertheyworketc.Once
established,toorderthemfrom Countrywideeventhough
more expensive.Previousmanagerorderedthemfrom eBay
and theybroke quite quickly.Aliciatocheckthisauditwhen
completed.
23.8.19 Lynne auditedsensorsand3 weren’tworking.
Deliverywithnewonesarrivedwhilstonsite.
Supervisionswithstaff notcompleted. Dawn Mullins notedthatsupervisionshadn’tbeencompleted
ina timelymanner. Dawnhasadvisedtoarchive the current
onesand start fromscratch, aimingtosupervise staff atleast
4 timesperyear. Jill tosupervise Sharon.Sharontosupervise
SeniorsandSeniorstosupervise care staff.House Keeperto
conduct domesticsupervision.Alltobe loggedandkeptin
staff files,withsignatures.

10. 26.7.19 3 supervisionsplusall domesticshave hadappraisals.
Supervisionsandconfidentialitypolicyhasbeenprintedfor
staff to sign. Everysupervision,anewpolicywillbe printed
and signed. Supervisionsforcare staff andappraisalsnext
time.
9.8.19 Seniorstocomplete carerson nights.Wednesdaysis
whenJill will be completingsupervisions.
23.8.19 Supervisionsare almostuptodate andwill nowbe
spacingthemout soall aren’tdue at the same time.
Appraisalsare goingtobe takingplace next.Supervisions
matrix evidenced.
Agencystaff notcompletinginductions. There isan expectationthatagencystaff will have the basic
training.Intermsof an ‘induction’,agencystaff are informed
of evacuationprotocols,call alarmsetc.Thisistobe lookedat
– a checklistwill identifywhatagencystaff needtoknowand
will be checkedoff andsigneduponcompletion.
26.7.19 Lynn(newmanager) saysagencyshe usedat another
home usedto senda listof trainingthe agencystaff has.Jill
thinksshe’ll change agencytoensure theygetalistof training
and can evidence this.Anygapscanthenbe explored.
9.8.19 Lynn to followupwiththisandwhenagencyisused,I
will evidence atraininglist.
23.8.19 Reliance Care Agency usedforstaff whenneeded.
Documenthandedtoagencyworkerswitha brief description
of residents,inductionchecklistcompletedwithsenior,staff
profilesare sentwithtraining/qualificationswithdatesand
picture of staff member.
Allocationandhandoverdocumentationnotadequate. Previouslyacommunicationbookwasinplace (3 perunit);
nowa handoversheethasbeenputinplace.See attached.
Staff are writingalot of informationonitat the momentas
are panicking(notwantingtomisssomethingoff) butintime
as it’simplemented,informationwillbe reducedandbe
relevant.Will be discussedinteammeetingstosee if working

11. and if anythingneedstobe changed.
26.7.19 Handoversheetsstill needworkbutstaff are relaxing
and startingto documentrelevantinformation.Tocontinue
checking.
9.8.19 Seniorsare to initial whenthey’ve readahandover.
Thisto be checkedonthe nextvisit.
23.8.19 handovernotesare nowbeinginitialledwhenread.
Staff are wantinga communicationbooktobe re-
implemented.Ihave advisedtokeephandovernotesabout
the resident(s)andthe communicationlogs aboutanything
else.
IPCtrainingnot upto date. Traininghasbeenreviewedandidentifiedasoutof date.All
staff are to refreshtraining–a planof actionis beingputinto
place intermsof timesstaff complete training.Thiswillbe
checkedonfuture visits.
26.7.19 Trainingmatrix provided.Lotsof traininghasbeen
completed.M&Hnearlyall staff upto date.Aliciastill waiting
for response fromPOD.
9.8.19 Still awaitingresponse.Aliciahassentalternative
informationregardingreactto red.Traininghasprogressed
verywell andmoststaff are upto date.
Some furniture iswoodenandnoteasilydecontaminatedandsome
edgesare rough. Commode frames are woodenandcan’tbe
decontaminatedeasily.
AliciaGasstondiscussedthiswith Jill andSharon atthe visiton
11.7.19 and itis deemednotappropriate tohave plastic
furniture withinaresidential home setting. Woodlands isnot
a clinical setting,itispeopleshome.There forwooden
furniture will notbe replaced,unlessdamagedorseriously
contaminatedbeyondthe abilitytoclean.
Cleanlinessof residentsrooms – stickycarpets. Some resident’s
mattressesandpillowsdidnothave imperviouscovers.Showerheads
and flooringnotclean.
Thishas beenidentifiedonaninfectioncontrol audit. Jill
hadn’tbeenaware of this.AliciaGasstonto senda copyof the
auditand actionsand Jill toimplementanactionplanto
rectifythe concernsnoted.
26.7.19 Pillowprotectorsandnewpillowsordered.New
handymanstartingMondayand he will be descalingshower

12. headsonce a month.Showerheadsare cleanedeveryday.
1 Sluice notusedbutworks.2 Sluiceshave beenorderedand
are awaitingdelivery.These will be installed.
Infectioncontrol auditconducted (evidenced) andwillbe
completedmonthly.
Some areascluttered. On AliciaGasston’svisiton11.7.19, some areas were
clutteredwithwheelchairsandequipment.Appropriate
storage needstobe soughtfor these itemsandtheywere in
corridorsor bathrooms.Aliciadiscussedthiswith Jilland
Sharonand it wasnotedthe equipmentshouldbe placedback
inthe resident’s roomwhennotinuse.
9.8.19 Dailywalkroundshave identifiedwhere clutterand
equipmentisandit’sbeingactionedstraightaround.
Laundry.One door usedfordirtyand clean.Nosegregationof soiled
and cleanclothing.
The laundryroom nowhas 2 doors.One inand one out.No
otherissues.
Unable to locate JobDescriptionsorcontracts. On AliciaGasston’svisiton15.7.19, contracts were seenbut
the start date wasMay 2018 andthe contract signedMay
2019. Jill istoconduct auditsoncontracts and job
descriptions.PriortoApril,noone hada contract and thisis
beingrectified.
26.7.19 To check at nextvisit. Jill hasseenevidence thatall
staff have contracts intheirfileswhichare signed.
9.8.19All staff,barnewstartersand staff on maternityleave
nowhave a signedcontract.
No audittrail forgrocery shopping. Asdashoptwice weekly,majorgroceriesfortnightly(Bidfood).
Receiptsandconfirmationemailsseen.
The previousmanagerhastakenthe workslaptop. The laptopis nowreturnedand Jill isworkingthroughthe
documentsonit.No otherissues.
Staff not fullyuptodate withtraining. A trainingmatrix hasbeencompletedwhichhasidentified
trainingneeds.Coursesare beingbookedforstaff,and
attendance ismandatory.Aliciawillcheckprogressatfuture
visits.
26.7.19 M&H addedto matrix (nolongerseparate) and

13. trainingbookedin forstaff andmajorityare upto date.
Trainingmatrix evidenced.
9.8.19 Trainingcoveredabove.Happywithprogressasmost
staff are upto date andmore workisbeingdone around
bespoke training.
Personal recordsare storedinarea the publiccan access. Recordsare nowstoredinlockable cabinets.
ActionPlanto be createdfor findingsinthe KingsFundTool. Thishas beenprintedoff andwill be completed.Thisislow
priorityuntil otherissueshave beenresolved.
There isno Dignity Champion. A DignityChampionistobe implementedasap.
26.7.19 Notappointedyet.
9.8.19 Not appointedyet.
23.8.19 NewmanagerLynne will be the dignitychampion.
Lack of Ownerinteraction AliciaGasstonheldadiscussionwith DennisandRaj on
15.7.19 regardinglackof ownerinteraction.Itbecame clear
that not enoughhadbeendone asa lot of trust inthe ex-
manager.Thoroughcheckswere notbeingcompletedat
auditsand insteadthe ex-managerswordwastaken.I
explainedthatif Dennishadbeencheckingthoroughlythen
we wouldn’tbe inorganisational safeguarding.Ihighlighted
that staff had approachedhimregardingthe ex-managerand
the fact Woodlands hasbeenawardedRIby CQC.He
understandsthathe didn’tdoenough.Infuture, Denniswill
be completingauditsonworkundertakeninrelationtothis
actionplace to check progress.
26.7.19 Raj conducteda registeredprovidersmonitoringvisit.
The audit ispoor.It’s notidentified anything;itjustrefersto
an actionplanfrom contracts. Dennisconductsauditsbuthas
admittedthathe didn’tcheck Debbie’s work.Didanaudit
yesterdayand Jill statedDenniswaschecking.
9.8.19 Denniswason site at today’svisit.Anauditwas
conductedon25.7.19 and Dennischeckedeverything. Jillis
makingsure these auditscontinue andeverythingischecked
thoroughlyandspokenwordisn’ttakenasgospel. Leavingas

14. amberuntil I can evidence these checksare continuing.
23.8.19 A furthervisithastakenplace 9.8.19. Report
evidenced.Will continue tocheckprogressatfuture visits.
CommunicationbetweenmanageranddeputyandManagementand
staff and vice versa.
A clearstructure needstobe implemented.
26.7.19 Jill toimplementstructure tree.
9.8.19 Jill workingonthis.
23.8.19 Structure tree completed,will be ondisplayinfoyer.
Inadequate audits. I.e. fallsandbaths/showers. Staff observations
and spotchecks.
Auditsare lackingand Jill isina positiontoimplementthese.
Withassistance fromAJC,auditswill be drawnupand
actioned.Aliciatocheckprogressonfuture visits.
26.7.19 IPCaudit,mealtime audit,dailyworkround,all
implemented. Medscompetenciesandmedsaudittobe
lookedat.Alsotolookat staff observations.
9.8.19 Jill evidencedastaff competencyformeds.All seniors
have thisand an annual refresheriscompleted.
Otherauditsongoing.
23.8.19, meds,care plan,IC,meals,dailylogs,bedalarms,falls
RA all auditsbeingcompleted.Evidenced,spotchecksetc.
Poormenuchoices On AliciaGasston’svisiton11.7.19, breakfastwasbeing
served.There wasrange of foodon offerlike cereals,
porridge,cookedbreakfastandtoast.All residentshad
differentmealsanditlookedappetising.Hotandcolddrinks
were offeredandresidentssaidtheyreallyenjoyedthe food.
At teatime,a range of sandwicheswere offeredwithcrisps,
juice andcake andresidentsappearedveryhappytoeatthis
as they’dhada hot meal and puddingatlunchtime.Judging
fromthe weightcharts,itindicatesresidentsreceiveagood
dietas mosthave gainedor maintainedtheirweights.If food
was pooror not enoughbeinggiven,thatwouldreflectinthe
feedbackfromresidentsaboutthe menuandalsothe weights
wouldbe decreasing.
27.7.19 On visitagood selectionof foodoffered.3week
rollingmenualsoprovided.

15. PEEPS needtobe updated. LastupdatedNovember2017. Identified
residentswhoare deceasedandothersaren’tdated.These are tobe
archivedandnewonesdraftedasap.
Due to poor documentation,aPEEPSreviewneedstotake
place and a protocol regardingevacuationneedstobe
implemented.Thisneedstoinclude aprotocol forheadcount.
Thisis to be addressedasa matterof urgencyby Jill andAlicia
will checkprogressbyendof nextweek(w/e 21.7.19).
26.7.19 Some progresshasbeenmade.Identifiednewer
versionsof the PEEPsalthoughsome were deceased. Jill is
goingto lookin everyone’s individual care file andensure
each hasa copyof the PEEPS as well as a central folder.The
template Jill hasatpresentislackinginformationso Jill is
seekingtosource a more detailedplan.
Fire officerattendingnextweektodelivertraining.FireRA has
beencompleted.
Handoverdocumentationincludesaheadcountandspace to
write isresidenthasleftthe building.
9.8.19 All completedandevidenced.Indepthwithclear
instructionforevacuationplans.Fileskeptineachunitanda
masterin the office.
BodyMapping notsufficient. BodyMaps needtohave bothtime and date addeddue to
problemsarisingfromaresidenthavinginjuriesanditnot
beingclearwhere these came from.
26.7.19 Newbodymapis verydetailedandhastable onthe
back for cleardocumentation.Will liaise withhospitaland
familyonadmissionandseeksignatures.Thenwhen
deliveringpersonal care,bodymappingwillbe completed
wholly.
9.8.19 Evidencedarecentadmission JW– hisnewcare plan
and documentswere verygoodincludingbodymap
completed.All relevantinformationsoughtincluding
informationregardinghiswife whoisalsoaresident.
GDPR breach – care documentsmissing.Alsohomesemail addressis Ownerto call resident’s familytoinformof breachandconsult

16. unsecure leadingtopotential databreaches. legal.A walkroundthe home needstobe performedtosee if
any otherbreaches.Email tobe lookedat – ex-managerhas
the passwordforcurrent email andisrefusingtogive itup.
UPDATE: Ownershave spokentofamilyandsenta lettervia
postand email.Legal have beeninformed.Copyof lettertobe
broughtto safeguarding.
26.7.19 depersonalisedthe boards,GDPRison dailywalk
round. Newemail address
woodlandslodgehoyland@outlook.com
Filesare keptlockedaway.
Outstanding:Passwordforoldemail.Ex-managerwon’t
provide.
9.8.19Email passwordnowobtained.Evidencedletterfrom
solicitorregardingbreachesandnotrequiredtoreporttoICO.
NFA.