CQC report explained · a nursing home
What the CQC found at Woodhall Park Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe medicines practice, staff trained to recognise abuse and risks assessed for falls, smoking and moving people. Emergency evacuation plans had also improved.
- Effective?
- Good
- People's choices, dietary needs and weights were considered. Staff had relevant training, and health professionals were contacted promptly when needed.
- Caring?
- Good
- People and relatives described staff as kind and caring. Inspectors saw privacy, dignity, independence and family involvement being supported.
- Responsive?
- Good
- Care plans reflected people's preferences and staff used information about people's lives to plan activities. A complaints procedure was available, although there had been no formal complaints since the previous inspection.
- Well-led?
- Good
- The two registered managers had introduced more structured checks, including maintenance, medicines and falls audits. People's views were collected and the provider had improved its notifications to CQC.
What inspectors found, February 2018
Woodhall Park Nursing Home was rated Good; inspectors found safe, kind and personalised care, with improvements made since the previous inspection.
Inspectors visited unannounced on 15 January 2018. They spoke with people living in the home, relatives, staff and health professionals. They also reviewed care records, staff training and the home's checks on quality.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines practice, good support with health and nutrition, respectful care and activities based on people's interests.
The previous inspection in November 2016 had rated the home Requires Improvement. The provider had been asked to improve safety and how the home was managed. Inspectors found these improvements had been made.
Enough staff
Inspectors found enough staff to meet people's physical and social needs. Staffing had been increased after feedback that some people had waited for support.
“There were sufficient numbers of staff available to effectively support people.” from the report
Safe medicines
Staff who gave medicines had training and regular competency checks. Inspectors found medicines were stored safely and available in the correct amounts.
“People received their medicines safely from staff who had been trained to carry out this task.” from the report
Kind relationships
People and relatives described warm relationships with staff. Inspectors saw staff taking time to communicate in ways suited to each person.
“People had established positive relationships with staff and felt they supported them.” from the report
Personalised care
Care plans included people's preferences, such as how they liked their hair, clothes and care to be provided. Families were involved in reviewing plans.
“The care plans were personal and identified individual aspects of peoples care.” from the report
Improved management
The managers had introduced regular checks and used them to identify and reduce risks. The previous problems with audits and reporting had been addressed.
“Other audits had been used to drive improvements.” from the report
Privacy improvements were still planned
minorSome people shared rooms, although screens were available. A bathroom near reception was due to be extended and its access changed to make personal care more discreet.
“Plans had been developed to extend the bathroom and change the access to make it more discreet for people.” from the report
- 01Have the planned changes to the bathroom near reception been completed, and how is privacy protected while people use it?
- 02How many staff are on duty at different times of day, and how do you increase staffing when people's needs change?
- 03How are medicines checked now, including medicines given through a PEG?
- 04How are families involved in reviewing care plans and reporting changes in a person's needs?
- 05What activities are available for someone with this person's interests, abilities and communication needs?
This was an unannounced inspection of the overall service and all five key questions; inspectors found improvements since the November 2016 inspection. This explanation was written from the published report of 7 February 2018 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 2016
Rated Requires Improvement; inspectors found kind and responsive care, but safety arrangements and management systems were not reliable enough.
This was an unannounced inspection on 8 November 2016. Inspectors spoke with people using the home, relatives, staff and health professionals. They also reviewed care records, staff files, training records and quality checks.
There had been improvements since the previous inspection, especially with medicines and consent. However, staffing was not always consistent, some staff could not explain safeguarding procedures, and there were no individual evacuation plans for emergencies.
People were treated with dignity and respect. Inspectors found good support with food, health needs, choices, activities and end-of-life care. However, records, audits, maintenance checks and notifications to the CQC were not managed well enough.
The overall rating is Requires Improvement. Effective, Caring and Responsive were rated Good. Safe and Well-led were rated Requires Improvement.
Kind and respectful care
People said they felt cared for, and inspectors saw staff treating people with dignity. Staff knew people well and maintained important relationships.
“People told us staff knew them well and had established relationships with them.” from the report
Good choices and activities
People could make choices about food, where they spent time and what activities they joined. Care plans included their preferences.
“People were encouraged to be independent and had choices about how they filled their time.” from the report
Improved medicines management
Medicines were given as prescribed, including medicines with specific timing requirements. Records, storage and stock checks were in place.
“This meant people received their medicine as prescribed to support their health needs.” from the report
Health and nutrition support
The home sought advice from health professionals when people had health, eating or swallowing concerns. Staff followed the guidance provided.
“We saw that referrals had been made to health care professionals in a timely manner and any guidance followed.” from the report
Support at the end of life
Inspectors found individual and compassionate care for people nearing the end of their life. Pain relief and people's wishes were monitored and recorded.
“We saw that when people were nearing the end of their life, they were supported with compassionate and individual care.” from the report
Staffing was not always consistent
seriousAfter 4pm, fewer staff had an impact on support. A lounge was left without staff for periods of 15 minutes and tea was delayed.
“We observed that when the staffing numbers were reduced by one after 4pm it did have an impact on the support people received.” from the report
Emergency evacuation planning
seriousThere were no plans explaining how each person would be supported in an emergency evacuation. This was particularly important because many people needed help to leave the building.
“There were no plans in place to provide staff with information on how to support people in the event of an emergency such as a fire or any other incident that required the home to be evacuated.” from the report
Safeguarding understanding
seriousSome staff could not explain how to protect people from harm or how to report concerns. The managers had not completed competency checks to confirm that staff understood their training.
“However, other staff we spoke with were unable to explain how to protect people from harm and the methods of reporting.” from the report
Weak quality monitoring
seriousAudits did not consistently analyse incidents, identify trends or make sure actions were completed. This included delays in responding to a person's weight loss.
“This is a continued breach in Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Unclear care records and handovers
needs fixingThere was no separate record showing all care delivery and checks for individuals. Handover notes did not always explain what action was needed or when follow-up was due.
“This meant we could not be sure people's needs were identified and followed up.” from the report
Maintenance and notifications
seriousSome repairs had not been completed for over two weeks, and water-check records were unavailable. The home had also failed to notify the CQC about important events.
“The provider had not notified us about important information affecting people and the management of the home.” from the report
- 01How are staffing levels covered after 4pm, and how will you prevent delays or areas being left without staff?
- 02What individual evacuation plans are now in place for people who would need help or equipment in an emergency?
- 03How do you check that every staff member understands safeguarding and knows how to report concerns?
- 04How are care records and handovers checked so that repositioning, fluid intake, medical checks and follow-up actions are recorded clearly?
- 05What changes have been made to quality audits, maintenance records and CQC notifications since this inspection?
This was an unannounced comprehensive inspection covering all five key questions and the overall rating. This explanation was written from the published report of 6 December 2016 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 Park Nursing Home
3 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- February 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 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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