CQC report explained · a residential care home
What the CQC found at Woodheyes
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2021
Rated Requires Improvement; inspectors found the home safer overall, but its checks on people's decision-making and quality were not reliable enough.
This was an unannounced focused inspection on 31 March 2021. Inspectors checked whether earlier improvements had been made in Safe and Well-led. They spoke with five people, 10 relatives and 11 staff, and reviewed care, medicine, recruitment and management records.
The Safe rating improved from Inadequate to Good. People were protected from abuse, medicines were managed safely and infection control had improved significantly. However, some medicine cream records were incomplete, and staff gave mixed views about staffing levels.
The Well-led rating improved from Inadequate to Requires Improvement. Checks on mental capacity and falls records were not robust enough, and relatives and some staff were not always involved as fully as they should have been.
The home had been in Special Measures after the previous inspection and conditions had been placed on the provider's registration. It was no longer rated Inadequate or in Special Measures after this inspection, but further improvement was needed and had to be sustained.
Improved infection control
Inspectors found major improvements in infection prevention and control. Government guidance about COVID-19 was being followed.
“Significant improvements were made to infection prevention and control measures.” from the report
Protection from abuse
People and relatives said people were safe. Staff had safeguarding training and knew how to report concerns.
“People were protected from harm and abuse. Records showed safeguarding concerns were reported to the local authority and CQC.” from the report
Safe medicines
People received medicines as prescribed, and there were suitable instructions for medicines given when needed.
“Medicines were managed safely. One person told us, "I have tablets every day in the morning and in the night, they always ask can they give them to me, and always stay with me.” from the report
Positive atmosphere
People and relatives spoke positively about the staff and management. The home was described as friendly and welcoming.
“There is a warm, friendly and generally happy atmosphere in the home.” from the report
Mental capacity checks
seriousThree people's mental capacity assessments contained identical information. Inspectors said this could lead to decisions being made for people without properly understanding their individual circumstances.
“We reviewed three people's mental capacity assessments and found information was identical in all their assessments.” from the report
Quality checks
needs fixingSome audits did not reliably find problems. A falls audit had not been analysed for patterns and one record was missing.
“A falls audit on 3 March 2021 had not been analysed to identify any themes and trends, and one record was missing from the audit.” from the report
Staffing concerns
needs fixingStaff gave mixed feedback about staffing levels, with some saying there were not enough staff at busy times. People and relatives gave more positive feedback.
“You do your best but they [residents] just don't get the care they deserve as there aren't enough staff to go around, especially in the afternoons.” from the report
Family involvement
needs fixingRelatives were not always given the chance to take part in reviews of their family member's care.
“Relatives were not always provided with opportunity to be involved in reviews of their family members care needs” from the report
- 01How have you reviewed every person's mental capacity assessment since the inspection, and how do you involve relevant professionals and relatives?
- 02How do you check staffing levels during afternoons and other busy periods?
- 03How do you make sure falls audits identify patterns and that no records are missed?
- 04How will you involve relatives in regular reviews of their family member's care?
- 05How do you check that topical medicines are recorded every time they are given?
This was an unannounced focused inspection of Safe and Well-led only; the ratings for the other key questions carried over from the previous comprehensive inspection. This explanation was written from the published report of 20 May 2021 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, January 2021
Woodheyes was rated Inadequate and placed in special measures; inspectors found serious safety, care and management failures during a COVID-19 outbreak.
This was an unannounced inspection on 29 October and 2 November 2020. Two inspectors spoke with seven staff and reviewed care records, medicines records, policies and management records. They could not speak with residents because of the COVID-19 outbreak.
The home was experiencing an outbreak affecting 23 residents and 22 staff. Inspectors found serious problems with infection control, staffing, training, isolation, cleaning and oxygen therapy. They also found that care plans and risk assessments had not been updated, and that one seriously ill person experienced a delay in getting medical attention.
The home was rated Inadequate overall, for Safe and for Well-led. Caring was rated Requires Improvement. Medicines were managed safely, but this did not outweigh the wider risks. The home was placed in special measures, meaning CQC said it would keep the service under review and normally re-inspect within six months.
Medicines
Inspectors found that medicines were administered safely and records showed people received them as prescribed. Records for medicines given when needed also explained when and why they were used.
“Medicines were managed safely. We saw medicine administration record (MAR) charts were in place, these showed people received their medicines as prescribed.” from the report
Safeguarding awareness
Staff had received safeguarding training and knew how to recognise abuse and what action to take. The manager understood the responsibility to report concerns to relevant agencies.
“Staff received safeguarding training and were aware of the signs of abuse and what action they should take in response to any concerns they held for people's safety.” from the report
Communication with relatives
Relatives were kept informed about the COVID-19 outbreak. Earlier surveys had also given relatives, staff and professionals a chance to provide feedback.
“Relatives were kept informed about the outbreak of COVID-19.” from the report
Staffing and training
seriousThere were not enough staff to support safe isolation and some staff lacked the training needed for COVID-19 cleaning, PPE and safe care. No review of staffing levels had been completed after the outbreak.
“There were not enough care staff to support people to isolate effectively.” from the report
Dignity and respectful language
needs fixingInspectors saw that privacy and dignity were not always protected. They also heard a staff member use derogatory language about a resident.
“Staff did not always refer to people by their name and used derogatory language which showed a lack of understanding of people's needs.” from the report
Management oversight
seriousAudits and governance systems had lapsed and had not identified the problems found during inspection. The provider also did not put effective management cover in place while senior managers were absent.
“Systems and processes were either not in place or robust enough to demonstrate the regulatory activity was effectively managed.” from the report
- 01What changes have you made to infection control, PPE use, cleaning and isolation procedures since the inspection?
- 02How many staff are now on duty, and how do you assess whether staffing levels meet residents' needs during an outbreak?
- 03What COVID-19 and oxygen therapy training have staff completed, and how is their competence checked?
- 04How are residents' care plans and risk assessments now reviewed when their health or infection risks change?
- 05What conditions did CQC impose, and what evidence can you show of the improvements made since this report?
This was a focused inspection of Safe and Well-led, with Caring also reported; Effective and Responsive were not rated, and the inspection was prompted by concerns about a COVID-19 outbreak. This explanation was written from the published report of 21 January 2021 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 Woodheyes
5 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- May 2021Requires improvementcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- January 2021Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- July 2019Goodstayed GoodSafe: GoodCaring: OutstandingWell-led: Good
- November 2016Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- February 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 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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