CQC report explained · a nursing home
What the CQC found at Eden Holme Care
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2022
Woodlands Care and Nursing Home was rated Requires Improvement; inspectors found risks in care records, medicines, recruitment and management systems.
This was an unannounced, focused inspection on 12 July 2022. Inspectors checked whether the home was safe and well-led. They spoke with three people, 10 relatives and 10 staff, and reviewed care records, medicines records, recruitment files and management records.
The home had grown from 14 residents in February 2022 to 43 at this inspection. Inspectors found that risk assessments and care plans were not always complete or up to date. Medicines records did not always give staff the information they needed, and recruitment checks were incomplete.
The home was also not managing its quality systems well enough. Care records could be lost when the internet failed, overdue care plans were not identified, and concerns from families and staff were not always dealt with confidently. The overall rating changed from Good to Requires Improvement. The Caring, Effective and Responsive areas were not inspected at this visit, so their previous ratings were used in the overall result.
Mental capacity
Inspectors found that the home was working within the Mental Capacity Act principles and that required legal authorisations were in place where needed.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.” from the report
Infection control
Inspectors were assured about several infection prevention arrangements, including admissions, testing, hygiene and outbreak management. Staff corrected mask use during the inspection.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Safeguarding work
The home had an up-to-date safeguarding policy, and staff had safeguarding training. The provider worked with the local authority when safeguarding concerns were raised.
“The provider engaged with partner organisations when something went wrong.” from the report
Incomplete risk information
seriousSome people did not have clear or current guidance for falls, hygiene, distress or refusing meals. This meant staff might not know how to reduce risks or meet needs safely.
“Information about people's known risks was not always comprehensive.” from the report
Medicines records
seriousSome medicines records lacked timing instructions, medicine profiles or reasons for missed doses. Diabetes monitoring records were also not always completed correctly.
“Staff did not always have guidance to administer medicines correctly.” from the report
Recruitment checks
seriousSome of the seven staff files reviewed did not contain all required employment histories, reasons for leaving previous jobs or risk assessments. Inspectors said this could mean unsuitable staff supported people.
“The provider did not follow safe recruitment guidelines to ensure suitable staff were deployed in the service.” from the report
Weak management checks
seriousAudits did not identify overdue care plans, missing recruitment documents or medicines recording problems. Internet failures also caused gaps in care records without a backup arrangement in place at first.
“The provider did not implement effective systems to monitor and mitigate known risks in order to keep people safe.” from the report
Concerns not always resolved
needs fixingSome relatives and staff were not confident that concerns would be listened to or dealt with. Families and professionals also reported difficulty contacting the home by telephone.
“Stakeholders told us they were not always confident the issues they raised with the management team would be addressed appropriately.” from the report
- 01How have you updated risk assessments and care plans for falls, personal hygiene, distress and poor eating?
- 02What checks now make sure medicines are given at the right time and that missed doses and diabetes readings are recorded correctly?
- 03How do you check that every new staff member has completed employment history, references and required risk assessments before starting?
- 04What is the paper backup process when the electronic care record system or internet is not working?
- 05How can relatives raise concerns, and how will you show that each concern has been investigated and resolved?
This was an unannounced focused inspection of Safe and Well-led only; the other areas were not inspected and their previous ratings were used in the overall rating. This explanation was written from the published report of 8 October 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2022
Woodlands Care and Nursing Home rated Good; inspectors found safe, kind care and major improvements after the change of provider.
Inspectors visited without notice on 1 and 2 February 2022. They spoke with staff, contacted relatives and reviewed care, medicines, staff and management records. The inspection also checked infection control and COVID-19 vaccination requirements.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safer medicines systems, improved records, good infection control and kind support from staff who knew people well.
This was the first inspection since the home registered under the new provider. At the previous inspection under the former provider, the overall position included Requires Improvement and Well-led was Inadequate. The report says these areas had improved to Good.
Safer medicines
The new provider carried out a full medicines audit and introduced regular checks. Records included allergy and health information, and checks looked for errors or missing entries.
“There were robust and effective medicine checks and audits completed by the registered manager to identify any potential errors or omissions.” from the report
Kind and familiar care
Staff knew people well and supported them with kindness, dignity and reassurance. Relatives gave positive feedback about the care and staff approach.
“People received kind and caring support. People were being supported by staff who knew them well.” from the report
Improved environment
The provider had carried out substantial refurbishment, including flooring, colour schemes and some layout changes. Moving and handling equipment had also been checked and mostly replaced.
“Extensive improvement and refurbishment work had been carried out by the provider to ensure people lived in a safe environment.” from the report
Strong management systems
The provider introduced audits covering care records, safety, equipment and medicines. Inspectors found that identified shortfalls were acted on promptly.
“The provider had implemented effective checks to ensure the quality of service provided to people was monitored.” from the report
Activities co-ordinator not yet appointed
minorThere was no activities co-ordinator at the time of the inspection. Staff were supporting people with preferred activities, but a formal activities programme was still being developed.
“Although an activities co-ordinator was not yet appointed at the time of our inspection, we saw staff supported people to enjoy the activities they liked and preferred.” from the report
Electronic care plans still being introduced
minorThe provider was still implementing electronic care plans. The paper or existing care plans inspected were described as detailed and up to date.
“The provider was in the process of implementing electronic care plans systems which would further enhance delivery and monitoring of care to people.” from the report
- 01Has an activities co-ordinator now been appointed, and what regular activities are available?
- 02Have the electronic care plans been fully introduced, and how are changes to care needs checked?
- 03How often are medicines records audited now, and what happens if an error is found?
- 04What refurbishment or equipment improvements remain outstanding?
- 05How are relatives involved in reviewing care plans and decisions about care?
This inspection followed a change of ownership and included a specific check of infection prevention and control, while also reviewing the five quality areas and reporting updated ratings. This explanation was written from the published report of 16 February 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Eden Holme Care
8 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- October 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Inadequate
- October 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- January 2022
Registered with the Care Quality Commission on 24 January 2022.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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