CQC report explained · a residential care home
What the CQC found at Woodham Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2024
Woodham Lodge is rated Requires Improvement; inspectors found safe medicines and enough staff, but risks, the environment, records and oversight were not always managed well.
This was an unannounced inspection on 16 November 2023. An inspector and an expert by experience spent time with all six people living in the home. They spoke with two people, three relatives and four staff, and checked care plans, medicines records, recruitment records, risk assessments and the premises.
The home was not always safe or effective. Inspectors found gaps in risk assessments, care records, infection control, staff training and support plans. A kitchen refurbishment caused disruption and created risks, including problems with the environment and fire evacuation planning.
Medicines were managed safely and there were enough staff to support people. However, the home was rated Requires Improvement overall, and also Requires Improvement for Safe, Effective and Well-led. The previous overall rating was Good in 2017, so the rating has gone down.
Medicines
Medicines were recorded and given safely. Staff were trained and checked that people received the right medicine at the right time.
“People received the right medicine at the right time from staff who were appropriately trained to provide this care safely.” from the report
Staffing
There were enough staff to meet people's needs, including one-to-one support for activities and visits. Recruitment checks were also completed.
“The service had enough staff, including for one-to-one support for people to take part in activities and visits.” from the report
Food and health
People were supported with balanced diets, personalised menus and regular weighing where needed.
“People received effective support to maintain a balanced diet and personalised menus were available for people.” from the report
Safeguarding
Staff had safeguarding training and knew how to report concerns. Records of incidents and accidents were used to share lessons with staff and relevant bodies.
“Staff had training on how to recognise and report abuse and they knew how to handle any allegation of abuse appropriately” from the report
Risk assessments and safe care records
seriousRisk assessments and care records did not always contain the information needed to provide safe care. The report says this increased the risk of harm.
“Potential risks to people were not always assessed, monitored, or mitigated.” from the report
Environment and refurbishment
seriousThe kitchen refurbishment caused major disruption and created risks. Fire evacuation plans did not account properly for the changes, and areas of the home were being used for storage or food preparation.
“Peoples living environment was disrupted, the dining room was used for food preparation and conservatory area was being used to store the kitchen contents.” from the report
Infection control
seriousThe laundry did not have a clean and dirty system, creating a risk of cross-contamination. Medicine storage was also not always clean.
“The laundry did not have a clean and dirty system in place and cross contamination risks were found.” from the report
Staff training
needs fixingSome training was out of date or incomplete, including training linked to people's needs. CQC recommended that the manager review staff training.
“Some staff training needed updating and specific training to meet people's needs was required.” from the report
Records and decision-making
needs fixingSome decisions about people's care and living arrangements were not recorded. Two people shared a bedroom without support plans or best-interest decisions in place.
“The culture at the service did not always support person centred practices as two people shared a bedroom and there were no support plans or best interest decisions in place to support this.” from the report
Management oversight
seriousThe manager's audits did not identify and deal with problems effectively. Important care, risk and treatment records were missing or incomplete.
“Audits were carried out by the manager. However, these did not identify and address issues effectively.” from the report
- 01What action has been completed to remove the risks caused by the kitchen refurbishment?
- 02How are personal evacuation plans being updated and tested when the building or its use changes?
- 03How do you make sure every person has current risk assessments and personalised support plans?
- 04What has been done to improve laundry arrangements and the cleanliness of medicine storage?
- 05Which staff training was overdue, and how do you check that all staff have now completed the required training?
This inspection rated Safe, Effective and Well-led; the report says ratings for key questions not inspected were carried over from the previous inspection. This explanation was written from the published report of 5 January 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, November 2017
Woodham Lodge was rated Good; inspectors found kind, person-centred care, but noted gaps in mental capacity records and questions about night staffing.
Inspectors visited on 13 September 2017. They gave the home a Good rating overall and rated it Good for Safe, Effective, Caring, Responsive and Well-led. The rating remained Good, as it had been at the inspection in July 2015.
They observed staff with people, spoke with people, relatives, staff and a visiting professional, and reviewed care records, medicine records, staff files and management records. The registered manager was not present, but another manager and staff helped with the inspection.
Inspectors found safeguarding arrangements, risk assessments, recruitment checks, medicines systems and daytime staffing were safe. They also found staff were kind and knew people well, care plans were person-centred, activities and healthcare were supported, and the home had systems to monitor quality and handle complaints.
Some records and arrangements needed attention. Mental capacity assessments and best-interest decisions were not recorded at the inspection, although the provider said these were completed afterwards. Some staff training and supervision were overdue, topical medicine records were missing, staff meetings were infrequent, and inspectors asked for more information about shared sleeping night staff.
Kind and respectful staff
Inspectors saw calm, friendly interactions. Staff understood people well and responded to their communication and emotional needs.
“We found staff at the service were very welcoming. The atmosphere was relaxed and friendly.” from the report
Person-centred support
Care plans described people's routines, preferences and support needs clearly. People were supported with activities, hobbies, holidays and social occasions.
“Care and health plans are very person centred and up to date.” from the report
Safe medicines systems
Medicine records checked by inspectors had no gaps or anomalies. Staff were trained and their competence was checked regularly.
“Medicine administration records (MAR's) that we looked at were completed correctly with no gaps or anomalies.” from the report
Good continuity and knowledge
Many staff had worked at the home for years, and people had lived there for a long time. Inspectors found staff knew people's needs, preferences and communication methods well.
“The majority of staff had worked at the service for many years and people had lived at the service for over 20 years.” from the report
Night staffing needed clarification
needs fixingThe sleeping night staff member was shared between this home and another service on the same site. Inspectors asked the provider for more information and said they would follow this up.
“We have asked the provider for additional information about the current staffing arrangements on night duty and will follow this up outside of the inspection process.” from the report
Mental capacity records were incomplete
needs fixingStaff were making decisions they believed were in people's best interests, but the required assessments and decisions were not recorded in care plans during the visit. Management later said the records had been completed.
“People's care records did not contain decision specific mental capacity assessments and best interest decisions were not recorded within care plans.” from the report
Staff supervision and meetings were behind
minorSome staff supervision meetings were overdue, and staff wanted meetings to happen more often. Senior staff said these issues would be addressed.
“We noted some supervision was overdue.” from the report
- 01How does the current night staffing arrangement work, and is the sleeping night worker still shared with another service?
- 02Have all decision-specific mental capacity assessments and best-interest decisions been completed and added to care plans?
- 03Are topical medicine application records now in place for every person who needs creams or other topical medicines?
- 04How are overdue staff supervisions and training refreshers being monitored?
- 05How often are staff meetings now held, and how are staff ideas and concerns acted on?
This inspection covered all five CQC questions and included observations, discussions and checks of two people's care records and two staff files; the registered manager was not present. This explanation was written from the published report of 1 November 2017 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 Woodham Lodge
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- January 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2017Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- August 2015GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 20 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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