CQC report explained · a residential care home
What the CQC found at Woodcote Hall
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2023
Woodcote Hall was inspected but not rated; the previous Requires improvement rating remains, with safe staffing found but some records incomplete.
This was an unannounced targeted inspection on 22 March 2023. The CQC looked at staffing and recruitment, and also checked infection prevention and control. One inspector spoke with people, relatives and staff, observed care and checked recruitment files, rotas and training records.
Inspectors found enough staff to meet people's needs safely. Recruitment checks and references were completed before staff started, and staff were described as well trained. Infection prevention arrangements were also found to provide assurance.
There were gaps in some recruitment and induction records. The manager had identified these issues and supplied missing recruitment documents or completed further inductions. Senior staff did not always have enough time to complete paperwork.
This inspection was not a full review and did not change the overall rating. The service remains Requires improvement from the previous inspection, although the report says a later targeted inspection found the home was no longer breaching regulations.
Enough staff
Inspectors found there were enough staff to meet people's needs safely.
“People were supported by a sufficient number of staff to meet their needs safely.” from the report
Safe recruitment
The home carried out DBS checks and obtained satisfactory references before staff started work.
“People were supported by staff who were recruited safely.” from the report
Staff training
People, relatives and staff said training was sufficient, and inspectors found staff were supported to be competent.
“People and relatives told us staff were well trained.” from the report
Infection control
Inspectors were assured about infection prevention, use of protective equipment and managing possible outbreaks.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Incomplete recruitment records
needs fixingSome recruitment files were inconsistent and lacked required documents. The manager provided the missing documents after the inspection and had actions in place to improve the files.
“Staff recruitment files were not always consistent and there were some gaps in required documents.” from the report
Induction records
needs fixingSome historical induction records were incomplete. The manager repeated inductions where needed to check staff competence.
“The new manager had identified some gaps in induction records.” from the report
Time for paperwork
needs fixingStaff said they had enough time for care but not always enough time to complete documentation. The home was recruiting a deputy manager and planning to move to electronic records.
“Staff told us there were a sufficient number of staff to meet people's needs safely but more time was needed to complete paperwork.” from the report
- 01Have all recruitment files now been checked and completed, and how do you make sure required documents are kept consistently?
- 02Have all staff completed the additional inductions identified by the manager, and how is competence recorded?
- 03Has the home recruited a deputy manager to give senior staff more time for documentation?
- 04Is the planned electronic records system now in use, and has it improved the completion of care records?
- 05What is the progress of the new manager's application to become registered?
This was a targeted inspection of staffing, recruitment and infection control within Safe; it did not assess the whole Safe question or the other four questions, and it did not change the previous Requires improvement rating. This explanation was written from the published report of 25 April 2023 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, October 2022
Overall rating remains Requires Improvement; inspectors found improvements in risk management, infection control and oversight, but this was not a full inspection.
This was an unannounced targeted inspection on 31 August 2022. One inspector and one inspection manager reviewed infection control, risk management and how the home was governed. They spoke with three staff members and checked two people's care records and other records.
Inspectors found that the home had acted on the problems covered by earlier warning notices. Risk assessments, accident and incident reviews, infection control measures and management checks had improved. The home was no longer in breach of Regulations 12 and 17 in the areas checked.
The overall rating did not change and remains Requires Improvement. Safe was previously rated Requires Improvement and Well-led was previously rated Inadequate, but neither rating was reviewed in full during this visit.
Risk management
The home had put specific risk assessments and controls in place after earlier concerns. Staff understood the measures needed to reduce known risks.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 12.” from the report
Infection control
Inspectors were assured that the home was following current COVID-19 guidance, using masks and checking visitors. People had individual COVID-19 risk assessments.
“People were kept safe from the risk of cross infection because the provider had embedded current government guidance relating to infection, prevention and control for COVID-19.” from the report
Management oversight
The home had improved how it reviewed incidents and monitored risks. Daily meetings helped staff share concerns and record completed actions.
“The provider had improved their governance systems to improve their oversight of the home.” from the report
Not a full rating review
needs fixingThe inspection only covered selected areas. The overall Requires Improvement rating and the previous Safe and Well-led ratings were not changed.
“Targeted inspections do not change the rating from the previous inspection.” from the report
Care-plan checking process not yet in place
needs fixingA new process for checking that allocated staff had read people's care plans had been introduced but was not yet implemented at the inspection.
“This was not yet implemented but would help ensure staff met people's identified needs and the provider could monitor where staff had not read their plan of care.” from the report
- 01What is being done to maintain the improvements in risk assessments and accident and incident reviews?
- 02Has the new process for staff to read and sign people's care plans now been fully implemented?
- 03What checks are now made to ensure bowel monitoring records are completed and acted on?
- 04What is the current position on the manager's registration?
- 05When is the next comprehensive inspection expected, including a full review of Safe and Well-led?
This was a targeted inspection of selected areas of Safe and Well-led, including infection control, risk management and governance; the previous ratings and overall Requires Improvement rating were not changed. This explanation was written from the published report of 11 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.
Every inspection of Woodcote Hall
8 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- April 2023Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- October 2022Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- August 2022Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2021Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- July 2021InadequateSafe: InadequateEffective: InadequateWell-led: Inadequate
- June 2021Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not ratedWell-led: Inspected but not rated
- September 2020Requires improvementstayed Requires improvementSafe: GoodWell-led: Requires improvement
- January 2019Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2017Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Inspected but not ratedWell-led: Requires improvement
- April 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2019
Registered with the Care Quality Commission on 16 April 2019.
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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