CQC report explained · a residential care home
What the CQC found at Woodbridge Lodge Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were not always protected from avoidable harm. Inspectors found missed medicines, weak risk assessments, incomplete care records, unsafe or unclean bedding, and gaps in safeguarding arrangements.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Inspectors did receive positive feedback about staff kindness and respect.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Management and oversight were inconsistent. Audits and records did not reliably identify or address shortfalls, and the registered manager had recently retired while a replacement was being recruited.
What inspectors found, June 2022
Woodbridge Lodge Residential Home was rated Requires Improvement; inspectors found unsafe medicines and care records, poor cleanliness in some beds, and weak oversight.
This was an unannounced, focused inspection on 27 April 2022. Inspectors looked only at Safe and Well-led. They spoke with people, relatives and staff, observed care, and checked medicines, care records, recruitment and management records.
The home was not always safe. Some people did not receive medicines as prescribed. Records did not always show safe repositioning, personal care or fluid support. Five of six beds checked had unclean or stained bedding, and one had wet bedding. There were also gaps in safeguarding and risk management.
The home was making changes, but inspectors found that improvements were not yet fully in place or consistent. Audits and records had not identified or dealt with all problems. Staff recruitment checks were completed, people could receive visitors, and inspectors saw some safe care and kind interactions.
The overall rating changed from Good at the previous inspection to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected in this visit, so their previous ratings were carried forward.
Safe recruitment
The home completed checks on the staff recruitment records inspected, including previous employment and DBS checks.
“The checks included previous employment and Disclosure and Barring Service (DBS) checks” from the report
Some safe practical care
Inspectors saw staff support a person safely with a transfer and reduce a possible falls risk by adjusting footwear.
“During our inspection visit, we observed staff supporting a person to transfer from a chair to a wheelchair safely.” from the report
Kind and respectful staff
People and relatives gave positive comments about how staff treated them, and inspectors also observed caring interactions.
“We received positive feedback from relatives and people using the service about how caring the staff team were.” from the report
Visits supported
Relatives said they could visit, and inspectors saw people spending time with their relatives.
“We received feedback from relatives that they were able to visit their family members in the service.” from the report
Mental capacity safeguards
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” from the report
Medicines were missed
seriousRecords showed that people sometimes did not receive medicines because they were asleep, unwell, or medicines were unavailable. The reasons and follow-up actions were not recorded consistently.
“We were not assured people were receiving their medicines as prescribed.” from the report
Pressure and skin care records
seriousBedding was creased or crumpled, and records did not always show that people were repositioned as planned. A red area on one person's skin was not followed up clearly.
“Records of supporting people to reposition to reduce the risks of pressure ulcers developing did not evidence that people were supported in line with their care plans.” from the report
Poor cleanliness in beds
seriousFive of the six beds checked had unclean or stained bedding. One bed had wet bedding, and a toilet seat and medicine trolleys also needed attention.
“Five of the beds looked at had bedding which were unclean and stained, this included the bottom sheet and duvet cover.” from the report
Weak checks and records
seriousAudits had missed important problems, and some identified issues were not dealt with promptly. Care records did not always give staff clear guidance or show what care had been provided.
“The governance systems in place were not robust enough to identify shortfalls and address them.” from the report
Staffing concerns
needs fixingRelatives and staff gave mixed views about staffing levels, with particular concerns about weekends and staff visibility on some floors. The home was making changes to staff deployment.
“We received mixed feedback about if there were sufficient staff to meet people's needs.” from the report
- 01What has changed since the inspection to make sure every dose of medicine is given as prescribed and any missed dose is followed up?
- 02How do you now check bedding, repositioning and skin changes, and can you show us recent records or audit results?
- 03How do you make sure staff are visible and checking people on every floor, including at weekends?
- 04Who is currently managing the home while a permanent manager is recruited, and how is progress against the action plan checked?
- 05How are care plans and daily records checked to make sure they clearly describe people's risks, food, fluids and personal care?
This was a focused inspection of Safe and Well-led only; the other three key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 1 June 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, December 2019
Rated Good; inspectors found safe, kind and personalised care, with improvements since the previous inspection.
This was an unannounced, planned inspection on 13 November 2019. Inspectors spoke with people living at the home, relatives and staff. They observed care and reviewed care plans, medicine records, recruitment files and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were protected from avoidable harm, received their medicines safely, and had care plans based on their needs and choices.
Inspectors saw kind interactions and found that people could choose their routines, food and activities. Staff supported people to access health services, maintain relationships and make complaints.
The previous inspection rated the home Requires Improvement and found a breach of Regulation 12. Inspectors found that improvements had been made and that the home was no longer in breach.
Kind and respectful care
Inspectors saw staff treating people with kindness and compassion. People were supported to make choices and remain as independent as possible.
“People were treated with respect, kindness and compassion by staff in their approach when supporting people.” from the report
Safe medicines
Inspectors found regular medicine checks, safe storage and disposal, and guidance for medicines prescribed as needed. People received medicines safely and on time.
“People received their medicines safely and on time.” from the report
Personalised support
Care plans included people's physical and social needs, preferences and risks. People and relatives were involved in developing and reviewing care plans.
“People received personalised care that was responsive to their needs.” from the report
Improved management
The home had strengthened its governance systems since the previous inspection. Audits were used to identify issues and take action.
“Since our last inspection, the registered manager had developed the service governance systems to improve monitoring in order to identify issues and take appropriate action.” from the report
Previous staff turnover
minorRelatives told inspectors they were concerned about frequent staff changes. The manager said recruitment had stabilised staffing over the three months before the inspection.
“Relatives shared with us the concerns they had for the frequent changes of staff.” from the report
- 01How stable has the staff team been since the inspection, and how many permanent staff currently work at the home?
- 02How would people be supported if the lift stopped working again?
- 03How are care plans reviewed with residents and their relatives when needs or preferences change?
- 04What activities are available for someone with my relative's interests and communication needs?
- 05How are medicines prescribed as needed monitored and reviewed?
This was an unannounced planned inspection covering all five CQC questions, with all five ratings given as Good. This explanation was written from the published report of 12 December 2019 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 Woodbridge Lodge Residential Home
7 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- June 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Woodbridge Lodge Residential Home →
- December 2019Goodup from Requires improvementSafe: GoodWell-led: Good
Read what inspectors found at Woodbridge Lodge Residential Home →
- February 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2016Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- July 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- November 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 6 January 2011.
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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