CQC report explained · a nursing home
What the CQC found at Woodhall House
Not yet rated: the CQC has not published a rated inspection for this home, which is usual for a new registration.
What inspectors found, April 2024
Woodhall House was inspected but not rated; inspectors found safe medicine storage but serious gaps in medicine oversight and partnership with families.
This was an unannounced, targeted inspection on 06 December 2023. Inspectors looked at concerns about medicine processes and examined parts of Safe, Responsive and Well-led. They spoke with children, relatives, staff, managers and health professionals, observed medicines being given, and reviewed records and policies.
Inspectors found that medicines were stored safely and given in a way that respected young people's preferences. Staff had received medicine training. However, medicine records, policies, audits and procedures were not always accurate or followed. Some physical health monitoring was also incomplete.
The home was not always responsive or well-led. Families and outside professionals were not always included in care planning or told about important changes. The service was not rated because CQC does not rate the regulated treatment provided by a children's home that is also registered with Ofsted.
Safe storage and administration
Inspectors found that medicines were stored safely and administered in a way that respected young people's privacy, dignity and preferences.
“People were supported to receive their medicines safely.” from the report
Staff medicine training
All staff had completed medicine training and competency checks.
“All staff had received medication training and completed medication competency training.” from the report
Children's views heard
Children could raise concerns in regular meetings and at other times. Inspectors found that staff listened and responded.
“Staff listened to concerns raised by children and responded appropriately.” from the report
Staff support
Staff told inspectors they felt supported by managers and able to raise concerns. Inspectors also found evidence of mandatory training.
“Staff we spoke to told us that they felt well supported by the management team at Woodhall House.” from the report
Medicine records and procedures
seriousMedicine records contained unclear, unsigned or missing information. Procedures for as-needed medicines, medicines taken outside the home and controlled medicines were not always followed.
“We found that handwritten changes had been made to numerous MAR sheets and changes were unsigned.” from the report
Medicine oversight
seriousMedicine audits were completed by the wrong staff and did not identify errors. The report says this continued after the issue had already been highlighted internally.
“The provider's medicines policy states that medicine audits must be completed by a mental health nurse and registered manager.” from the report
Incomplete health monitoring
needs fixingOne child had not received a full physical health measurement since February 2023. The records did not clearly explain why or what attempts had been made.
“One child who had not had a full measurement of physical health since February 2023.” from the report
Out-of-date policies and scattered records
needs fixingMost policies needed review, and records were stored in different places. This made it difficult to understand how the child's overall care was being delivered.
“The current record keeping system made it a ifficult to understand how holistic care is being delivered.” from the report
- 01How are medicine records checked for unsigned changes, missing directions and duplicate entries before medicines are given?
- 02Who completes medicine audits now, and how will you show that errors are identified and acted on?
- 03How will parents, carers, people with parental responsibility and outside professionals be included in care planning meetings?
- 04How will you tell families and relevant professionals promptly about medicine changes?
- 05What has been done to complete missing physical health checks and keep the records together?
This was an unannounced targeted inspection of concerns about medicines, covering parts of Safe, Responsive and Well-led; the service was inspected but not rated and Effective and Caring were not included. This explanation was written from the published report of 6 April 2024 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 2023
Inspected but not rated; inspectors found important improvements, but some policies and records still needed strengthening.
This was a targeted inspection on 23 January 2023. It checked whether the home had acted on a previous Warning Notice about safe care and treatment and good governance. Inspectors spoke with children, parents and carers, staff and managers. They also reviewed policies, procedures and records.
Inspectors found that risk plans were more up to date and prescribed observations had been recorded consistently. Incident investigations were clearer, and managers had identified actions to reduce the chance of problems happening again. Audits were also being used more effectively to check the quality of the service.
Some work was still needed. Policies did not clearly explain how staff should record and manage lower-level incidents or all organisational risks. Actions from incidents were completed, but this was not always recorded on the incident forms.
The home was inspected but not rated. This does not mean the home was rated Good or Outstanding. The inspection was limited to specific concerns, and inspectors said they would assess the full Safe and Well-led questions at a future comprehensive inspection.
More complete risk plans
Risk management plans reflected the known risks for each child and gave staff more useful guidance to help keep children safe.
“All children had risk management plans which contained key information as well as now reflecting all risks that had been identified to support staff in keeping them safe.” from the report
Consistent observations
The home changed its observation records and provided extra training. Inspectors found that the sampled observations had been fully recorded.
“We sampled observation records between 1 January and 23 January 2023 for all three children who lived at the home, finding that they had been completed fully on all occasions.” from the report
Better incident investigations
Incident reports contained clearer information and managers had reviewed them and identified actions to reduce the chance of similar incidents happening again.
“Managers had reviewed all reported incidents and had documented actions that were needed to reduce the risk of similar incidents happening again.” from the report
Stronger oversight
Additional audits were being used to check whether observations were completed and whether improvements were being sustained.
“Recent records of audits along with observation records that we sampled indicated that improvements had been made and sustained as a result of this.” from the report
Incident records were incomplete
needs fixingInspectors found that actions identified after incidents had been completed, but this was not always recorded on the incident forms. This could make it harder for managers to confirm that every action had been completed.
“Although we found identified actions that we sampled had been completed, this had not been documented consistently on the incident reporting forms.” from the report
Policies for lower-level incidents
needs fixingThe provider had not yet updated its policies to explain clearly how staff should record and manage lower-level incidents.
“The provider had not yet updated policies and procedures to support staff by outlining the expectations of how to document and manage lower level incidents.” from the report
Policies for organisational risks
needs fixingThe provider needed clearer policies explaining how organisational risks should be identified, recorded, escalated and managed.
“Further work was needed to make sure that there were clear policies and procedures in place to support staff in how to document and manage all levels of risk.” from the report
- 01Have you now introduced the recommended policy for recording and managing lower-level incidents?
- 02How do you make sure that every action identified after an incident is recorded as completed?
- 03Have the formal policies for identifying, documenting, escalating and managing organisational risks been implemented?
- 04Was the revised governance structure implemented after the inspection, and what difference has it made?
- 05What will be covered at the next comprehensive inspection of the full Safe and Well-led questions?
This was a targeted inspection of specific parts of Safe and Well-led, following a Warning Notice; it did not assess the full five key questions and the service was not rated. This explanation was written from the published report of 24 February 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.
Every inspection of Woodhall House
Each visit the CQC has published, newest first, back to the day the home was registered.
- April 2024Inspected but not ratedcurrent ratingSafe: Inspected but not ratedEffective: Inspected but not ratedCaring: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inspected but not rated
- February 2023Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- November 2022Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- July 2022Inspected but not ratedSafe: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inspected but not rated
- September 2020
Registered with the Care Quality Commission on 17 September 2020.
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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36 live-in carers within about an hour of Newcastle upon Tyne
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Most charge £950 to £1,160 a week. 30 can care for a couple. 10 years' experience on average.
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