CQC report explained · a nursing home
What the CQC found at Woodland Park
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 risks were not fully assessed, monitored or managed. Safeguarding concerns were not always recorded, reported or investigated properly, and medicine records were not always complete.
- Effective?
- Requires improvement
- Needs assessments and care plans did not always include people's personal preferences or enough detail, including for end of life care. Staff had sufficient skills and worked with health professionals, but care planning was not consistent.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its rating carried over from the previous inspection.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its rating carried over from the previous inspection.
- Well-led?
- Requires improvement
- Quality checks did not reliably identify or manage risks. Problems included incomplete care records, unreliable call bell information, missed maintenance and fire safety checks, and an out-of-date training record.
What inspectors found, November 2022
Woodland Park is rated Requires Improvement; inspectors found risks, safeguarding records, care plans and management checks were not consistently good enough.
This was an unannounced focused inspection after concerns about care quality, safety, staffing, staff skills and equipment maintenance. Inspectors visited on 31 August and 14 September 2022. They spoke with people, relatives, staff and health professionals, and checked care, nursing, medicine, maintenance, fire safety and quality records.
The home was not always safe or well managed. Some risks, including falls, malnutrition, pressure damage and catheter care, were not fully assessed or explained to staff. Safeguarding concerns had not always been passed to the manager for investigation. Medicine records, call bell information, daily care records and maintenance checks were also incomplete or unreliable.
People received support from staff who had the skills and experience to meet their needs. Families and health professionals gave positive feedback about clinical care, staff support and the manager's response to concerns. However, four recent admissions did not have personalised care plans, and the inspection found breaches of four regulations.
The overall rating changed from Good at the previous inspection in May 2019 to Requires Improvement. This visit looked only at Safe, Effective and Well-led. The Caring and Responsive ratings were not inspected and carried over from the previous inspection.
Clinical support
Families and health professionals had confidence in the clinical care. Staff worked with other professionals to manage complex needs and arrange healthcare support.
“A health professional told us they had confidence in the clinical care people received” from the report
Staff skills
Inspectors found staff had enough skills and experience to meet people's needs. Staff received supervision and said they felt supported.
“Staff had sufficient skills and experience to meet people's needs.” from the report
Positive culture
The inspection found a positive culture and examples of people being supported to achieve better outcomes, including moving towards greater independence.
“The culture of the service was positive, and people were supported to achieve the best outcomes for them.” from the report
Working with others
Staff worked closely with health professionals, including specialist nurses, and made referrals when needed.
“Staff worked closely with tissue viability specialist nurses who told us staff were good at making referrals at the appropriate time” from the report
Risk assessments
seriousSome people did not have important assessments for falls, malnutrition or pressure damage. Care plans also lacked clear instructions for some medical devices and catheter care.
“Risks were not always fully assessed or monitored, and where risks had been assessed there was limited information to guide staff as to how to manage the risk safely.” from the report
Safeguarding records
seriousThree people's complaints that staff had been rough with them were recorded in a communication book but were not passed to the manager. This meant they were not investigated or referred to the local authority at the time.
“Systems did not work effectively to ensure safeguarding concerns were appropriately recorded, reported and investigated.” from the report
Personalised care plans
seriousFour recent admissions did not have personalised care plans. End of life care plans were also not in place, so staff might not know people's wishes and preferences.
“Four people who were admitted to the home in July and August had no personalised care plans in place” from the report
Medicine records
needs fixingPeople received medicines safely, but records did not always show that medicines were given at the right time. Some insulin dates and staff signatures were missing.
“Staff did not always record when they administered timed medicines.” from the report
Call bells and staffing
needs fixingSome people and relatives reported long waits for call bells, particularly at night. The faulty call bell system meant managers could not reliably tell how long people waited.
“28% of call bells ringing for 4 minutes or longer, with just over half of those ringing for between eight minutes and one hour.” from the report
Management checks
seriousAudits did not consistently identify problems or assign action. Some repairs and routine fire and legionella tests had not been completed for several weeks.
“Quality assurance systems did not always identify or manage risks and regulatory requirements.” from the report
- 01What has been done to make sure every person has up-to-date, personalised care and end of life plans?
- 02How are falls, malnutrition, pressure damage, catheter care and medical devices now assessed and monitored?
- 03How do you now record, report and investigate safeguarding concerns?
- 04What has been repaired or replaced in the call bell system, and how do you check response times?
- 05How are medicine records, fire tests and other maintenance checks audited and followed up?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their ratings carried over from the previous inspection. This explanation was written from the published report of 25 November 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.
What inspectors found, May 2019
Rated Good; inspectors found kind, personalised care and strong leadership, with some medicines, food and infection-control improvements still needed.
Inspectors visited without warning on 27 March 2019. They spoke with people living at the home, relatives and staff, and checked care records, medicines, risk records, audits, complaints and policies.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People were treated with kindness and respect, involved in their care and supported by staff who knew their needs well.
Inspectors found that risks were assessed, staffing was sufficient and medicines were generally given as prescribed. They recommended updating the medicines policy and noted issues with food temperature and choice, hand-washing facilities in one bathroom and recording some equipment replacements.
This was a follow-up inspection. The home had previously been rated Requires Improvement overall, including for Safe and Well-led, at the inspection in February 2018. Inspectors found that improvements had been made and rated the home Good.
Personalised care
Care was planned around people's needs, wishes and preferences. Staff knew people well and supported them to make choices and remain independent.
“People received personalised support which met their needs and preferences.” from the report
Kind staff
Inspectors saw staff engaging warmly with people. People and relatives described the staff as caring, respectful and willing to help.
“People were supported by kind and caring staff.” from the report
Safe staffing and risk management
The home had enough staff with appropriate skills. Risks such as falls, pressure damage, poor nutrition and ill health were assessed and acted on.
“There were enough staff to ensure people had access to the care that met their needs and protected them from risks.” from the report
Positive leadership
The home had a strong, open culture. Quality checks were in place, and the manager used incidents, feedback and outside advice to improve care.
“There was strong leadership at the service. People and staff spoke highly of the management team” from the report
Medicines policy
needs fixingPeople received their medicines as prescribed, but the written policy did not fully match current professional guidance. The home said it was taking action to update its policy and practice.
“We recommend the service ensure the medicines administration policy is updated in line with professional guidance, to include covert medicines administration, transcribing of changes to prescriptions and 'as required' medicines procedures” from the report
Food temperature and choice
needs fixingSome people said meals were not always hot enough in their rooms, and some did not always enjoy the meals or feel there was enough choice. The manager said changes were being planned.
“Some people who chose to eat in their rooms told us the food they received was not always hot enough when it reached them.” from the report
Hand-washing facilities
needs fixingOne bathroom and toilet did not have hand-washing facilities. The manager said they would review how that room was used.
“One bathroom and toilet did not have hand-washing facilities.” from the report
Equipment records
minorThe home was not recording every replacement of some short-term healthcare equipment. Staff understood when replacements were needed, and the manager said this would be recorded in future.
“Some replacement of short term use healthcare equipment was not being recorded, for example oral syringes for feeding systems, catheter bags or oxygen masks and tubing.” from the report
- 01What changes have been made to the medicines administration policy, including 'as required' medicines and covert medicines, and how is staff practice checked?
- 02Has the heated food trolley been provided, and how are meal temperature, quality and choice now monitored?
- 03Does every bathroom and toilet now have suitable hand-washing facilities?
- 04How are replacements of oral syringes, catheter bags, oxygen masks and tubing recorded now?
- 05How will the home involve a new resident in conversations and decisions about end of life care?
This was an unannounced follow-up inspection covering all five key questions, including the care provided and the premises of this care home with nursing. This explanation was written from the published report of 3 May 2019 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 Park
4 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- November 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2019Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- April 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 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.
- March 2011
Registered with the Care Quality Commission on 23 March 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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21 live-in carers within about an hour of Torbay
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Most charge £980 to £1,400 a week. 17 can care for a couple. 12 years' experience on average.
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