CQC report explained · a nursing home
What the CQC found at Woodland Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risk assessments for epilepsy and diabetes were missing or lacked important information. Staffing, recruitment, premises safety and infection control were positive, although inspectors found three unexplained gaps in medicines administration records.
- Effective?
- Good
- This question was not inspected during this visit. Its rating was carried forward from the previous inspection.
- Caring?
- Good
- This question was not inspected during this visit. Its rating was carried forward from the previous inspection.
- Responsive?
- Good
- This question was not inspected during this visit. Its rating was carried forward from the previous inspection.
- Well-led?
- Requires improvement
- The home had a positive culture and clear management roles, but its quality checks had not identified the gaps in care plans and risk assessments. Inspectors said the monitoring systems were not effective.
What inspectors found, January 2023
Woodland Nursing Home was rated Requires Improvement; inspectors found gaps in risk assessments and quality checks, although staffing, medicines and infection control were mostly safe.
This was an unannounced, focused inspection on 23 November 2022. Inspectors spoke with people, relatives and staff, observed care, and reviewed care records, medicines records and management documents.
The home was rated Requires Improvement for Safe and Well-led. Risk assessments for epilepsy and diabetes were missing or not detailed enough. The home's checks had not found these problems, and inspectors said this placed people at risk of harm.
There were enough staff, recruitment checks were suitable, and medicines were mostly managed safely. The home was clean and infection control arrangements had improved since the previous inspection.
The overall rating stayed at Requires Improvement. The previous inspection in 2019 had also rated the home Requires Improvement, and the earlier concern about ineffective quality checks had not been fully addressed.
Enough staff
Inspectors found enough staff, and people and relatives also said staffing levels were adequate. Staff were observed responding promptly and were not rushed.
“There were enough staff to support people in a safe way.” from the report
Clean and infection controls improved
The report says earlier infection control concerns had been addressed. Inspectors were assured that the home had suitable arrangements for preventing and managing infection.
“During this inspection we found these had been addressed.” from the report
Positive culture
Staff described good teamwork and people and relatives spoke positively about the senior staff. Managers and staff understood their roles.
“The service had an open and positive culture to help achieve good outcomes for people.” from the report
Safeguarding systems
The home had procedures for reporting suspected abuse, and records showed that allegations had been reported appropriately.
“Systems and processes were in place to protect people from the risk of abuse.” from the report
Incomplete health risk assessments
seriousSome people with epilepsy or diabetes did not have the required risk assessment. Other assessments did not explain important information, such as blood glucose ranges or symptoms of a hypo or hyperglycaemic episode.
“Risk assessments did not always contain sufficient information to promote people's safety.” from the report
Quality checks missed problems
seriousThe home's audits and monthly reviews had not identified the gaps in care plans and risk assessments. This was also a concern at the previous inspection.
“Quality assurance and monitoring systems used by the provider were not always effective.” from the report
Gaps in medicines records
needs fixingInspectors found three unexplained gaps in the medicines administration records they reviewed. The manager said these would be investigated.
“We found that medicines were mostly managed in a safe way, although we did find 3 unexplained gaps on medicines administration records [MARs] we looked at.” from the report
- 01What has been changed to ensure every person with epilepsy or diabetes has a detailed, up-to-date risk assessment?
- 02How do managers now check that care plans and risk assessments contain the information staff need?
- 03What caused the three unexplained gaps in the medicines administration records, and what has been done to prevent this happening again?
- 04When will the provider complete the action plan requested by the CQC, and how will families be told about progress?
This was a focused inspection of Safe and Well-led only; the other question ratings were carried forward from the previous inspection. This explanation was written from the published report of 4 January 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.
What inspectors found, March 2022
Inspected but not rated; inspectors found well-managed infection control during a recent COVID-19 outbreak.
This was an announced, targeted inspection on 10 February 2022. It focused on infection prevention and control during CQC reviews of care homes with COVID-19 outbreaks. Inspectors also asked about staffing pressures.
The home had safe arrangements for visitors, including testing, temperature checks and personal protective equipment. People with COVID-19 were kept in a separate part of the building with a designated staff team.
Inspectors found that staff and people had received COVID-19 vaccinations, testing was routine, and staff used protective equipment correctly. The home was visibly clean, with cleaning schedules and infection control audits in place.
The home was inspected for safety but not given a rating. The other four areas were not assessed in this inspection.
Visitor safety
Visitors were tested before entering, had protective equipment available and could see people in person in line with government guidance at the time.
“People were able to see visitors in person, which was beneficial to their emotional and personal wellbeing.” from the report
Outbreak management
People with COVID-19 were accommodated separately and supported by a designated staff team to reduce the risk of infection spreading.
“There had recently been an outbreak of COVID-19 at the service and this had been managed in a safe way.” from the report
Clean premises
The home had cleaning schedules, infection control audits and a plentiful supply of protective equipment. Inspectors saw that the premises were visibly clean.
“We saw the premises were visibly clean on the day of our inspection.” from the report
Inspectors raised no specific concerns in this report.
- 01What measures are currently in place to manage staffing pressures, and have these affected people's care?
- 02Are visitors still asked to take a COVID-19 test and use personal protective equipment?
- 03How often are infection prevention and control audits carried out, and can families see the latest findings?
- 04What arrangements would be used if there were another infection outbreak?
- 05What are the home's current ratings for caring, effective, responsive and well-led care?
This was a targeted inspection of infection prevention and control and staffing pressures; only Safe was inspected and it was not rated, while the other areas were not assessed. This explanation was written from the published report of 4 March 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.
Every inspection of Woodland Nursing Home
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- January 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2022Inspected but not ratedSafe: Inspected but not rated
- July 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- June 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2016GoodSafe: GoodEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 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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