CQC report explained · a residential care home
What the CQC found at Woodfalls Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- People generally felt safe and staff understood how to manage risks. However, records for emollient creams were inconsistent, and the report described an earlier incident involving an unchecked emergency member of staff.
- Effective?
- Good
- This question was not inspected during this focused inspection. The previous comprehensive inspection rating was carried forward.
- Caring?
- Good
- This question was not inspected during this focused inspection. The previous comprehensive inspection rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this focused inspection. The previous comprehensive inspection rating was carried forward.
- Well-led?
- Good
- Inspectors found effective quality checks, improved management oversight, good communication with people and staff, and strong links with health and social care professionals.
What inspectors found, January 2022
Woodfalls Care Home was rated Good overall, but inspectors found medicines records were not always complete and rated safety Requires Improvement.
This was an unannounced focused inspection on 8 and 17 December 2021. Inspectors looked at Safe and Well-led because of concerns about staffing. They spoke with people, staff, relatives and health professionals, and checked care, medicines, staff and management records.
The home was rated Requires Improvement for Safe. People generally said they received medicines on time and felt safe. However, records did not consistently show that emollient creams had been applied. Inspectors also found that an unchecked member of staff had been used during an earlier staffing emergency, although this person was supervised and later staffing arrangements were strengthened.
The home was rated Good for Well-led. Inspectors found better quality checks, clearer management oversight, good safeguarding systems and effective work with health and social care professionals. The overall rating improved from Requires Improvement at the previous comprehensive inspection to Good.
This inspection did not examine Caring, Effective or Responsive. The ratings for those areas from the previous comprehensive inspection were used in the overall rating.
Infection control
Inspectors found that infection prevention and control arrangements had been maintained and updated for the COVID-19 pandemic.
“At this inspection the provider had maintained good infection prevention and control practice.” from the report
Risk management
Care records identified risks and explained the support people needed. Staff understood the actions required to keep people safe.
“Staff demonstrated a good understanding of risk management plans and the actions they needed to take to keep people safe.” from the report
Management oversight
The home had improved its checks on care records, medicines, staff records and staff practice. Incidents were reviewed so that lessons could be learned.
“The provider had effective quality assurance systems in place.” from the report
Working with other professionals
Inspectors found good working relationships with local health and social care professionals, and people were involved in giving feedback.
“The registered manager worked well with the local health and social care professionals.” from the report
Incomplete cream records
needs fixingRecords did not always show that prescribed emollient creams had been applied. Inspectors made a recommendation that medicine recording procedures should be followed consistently.
“However, the records for people prescribed emollient creams were inconsistent, with some days when there was no record of people being supported to use the cream.” from the report
Earlier staffing emergency
seriousDuring a staffing shortage, an unchecked person was used for one shift. The person was supervised, and the home later strengthened its staffing contingency arrangements and recruitment checks.
“An incident occurred in which they needed to use a member of staff in an emergency who had not been thoroughly checked.” from the report
- 01How do you now make sure every prescribed emollient cream application is recorded?
- 02What staffing arrangements are available if several staff are off sick at the same time?
- 03How do you check that every new staff member has completed the required recruitment checks before working?
- 04What recent audits or checks have you completed on medicines and care records?
- 05Which ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led only; the other key-question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 6 January 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 2020
Woodfalls Care Home was inspected but not rated; inspectors found improvements in infection control, while the overall previous rating of Requires Improvement remains.
This was an unannounced, targeted inspection on 19 November 2020. One inspector checked whether the home had followed a Warning Notice about safe infection prevention and control.
Inspectors found that enough improvement had been made and the home was no longer in breach of Regulation 12. Staff were using protective equipment correctly, and staff and residents were regularly tested for COVID-19.
The inspection only looked at specific concerns within the Safe question. It did not review the whole service, so the overall rating was not changed and remains Requires Improvement.
Protective equipment
Staff had received training and were using protective equipment in line with current guidance. They also knew how to remove and dispose of it safely.
“Personal protective equipment (PPE) was being used effectively and safely. Since the last inspection the registered manager had provided information and training to all staff on what PPE was needed and how to use it safely.” from the report
COVID-19 testing
The home was regularly testing staff and residents. It also had procedures to isolate people who tested positive.
“Staff and people who used the service were being regularly tested for COVID-19. The provider had procedures in place for people to be isolated if they tested positive.” from the report
Keeping families in contact
Residents were supported to stay in touch with family and friends by video call. The manager was also keeping relatives informed about plans for physical visits.
“People were supported to keep in contact with family and friends through video calls.” from the report
Moving into the home
needs fixingPeople were tested before moving in, but inspectors noted that current guidance also recommended 14 days of isolation in the home for people arriving from their own home. The manager was signposted to this guidance.
“Current guidance recommends that people should also isolate in the home for 14 days when they move in from their own home.” from the report
- 01How do you make sure all staff use and dispose of protective equipment correctly?
- 02What happens if a staff member needs to self-isolate, and are there enough staff to cover the absence?
- 03How do you apply current isolation guidance when someone moves into the home from their own home?
- 04How often are residents and staff tested for COVID-19, and what happens after a positive result?
- 05When will the next comprehensive inspection take place, covering the whole service?
This was a targeted inspection of specific infection prevention and control concerns within Safe; it did not assess the whole Safe question or the other key questions, so the previous ratings carried over. This explanation was written from the published report of 16 December 2020 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 Woodfalls Care Home
5 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- January 2022Goodcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2020Inspected but not ratedSafe: Inspected but not rated
- November 2020Inspected but not ratedSafe: Inspected but not rated
- February 2020Inspected but not ratedSafe: Inspected but not rated
- October 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- September 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 30 December 2010.
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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