CQC report explained · a nursing home
What the CQC found at Woodlands Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment, suitable risk assessments, safe medicines processes and effective infection prevention. People were able to receive unrestricted visits.
- Effective?
- Good
- This question was not inspected in detail during this visit. Its rating was carried forward from the previous inspection.
- Caring?
- Good
- This question was not inspected in detail during this visit. Its rating was carried forward from the previous inspection, although people and relatives gave positive feedback about the care.
- Responsive?
- Good
- This question was not inspected in detail during this visit. Its rating was carried forward from the previous inspection.
- Well-led?
- Good
- Inspectors found embedded quality monitoring systems, action plans for shortfalls and a positive, person-centred culture.
What inspectors found, June 2023
Rated Good; inspectors found safe, kind and well-managed care, with improvements since the previous inspection.
This was an unannounced focused inspection on 3 and 4 May 2023. One inspector and an Expert by Experience spoke with people, relatives and staff, and checked care, medicine, recruitment and management records.
The home was rated Good overall. Inspectors rated Safe and Well-led as Good. They found enough trained staff, safe recruitment, suitable risk checks, safe medicines processes and effective infection control.
People and relatives spoke positively about the care and the staff. The home was clean, homely and welcoming. Care plans were up to date, visits were unrestricted and activities were available.
The previous rating was Requires Improvement, published in January 2022. The home had been in breach of Regulation 17 at that inspection, but inspectors found enough improvement and confirmed it was no longer in breach.
Safe staffing and training
Staff had appropriate training and support. Inspectors found enough staff to meet people's needs and saw staff spending meaningful time with people.
“Staff received appropriate training and support. Regular supervision meeting and training checks were completed by the registered manager.” from the report
Safe medicines
People received medicines as prescribed. Records were completed and regular audits checked that medicines processes were being followed.
“People received their medicines in line with prescribers' instructions, appropriate documentation was in place and completed to demonstrate this.” from the report
Kind, person-centred care
People and relatives described staff as kind and spoke positively about the care. Inspectors found that care supported people's different needs.
“People received a high standard of person- centred care and support to meet their diverse needs.” from the report
Strong management checks
The home had quality checks and completed action plans when audits found shortfalls. Staff and managers used incidents and lessons learned to improve care.
“Systems to manage quality within the service were followed and fully embedded.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you now check that staff training and supervision remain up to date?
- 02How are risks to my relative assessed, reviewed and shared with staff?
- 03How do you audit medicines and respond if a medicines error or missed dose occurs?
- 04What improvements have been made since the previous inspection, and how do you check that they have lasted?
- 05What activities and visiting arrangements would be available for my relative?
This was a focused inspection of Safe and Well-led; the Effective, Caring and Responsive ratings were carried forward from the previous inspection. This explanation was written from the published report of 28 June 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, January 2022
Rated Requires Improvement; Woodlands Nursing Home improved from Inadequate and left special measures, but training gaps and weak governance remained.
This was an unannounced focused inspection on 1 December 2021. Inspectors looked at Safe and Well-led, spoke with people, relatives and staff, and checked care, medicine, recruitment and management records.
The home had improved since its previous Inadequate rating. Recruitment, care plans, risk assessments and infection control had improved. Medicines were generally managed safely, but some records and processes still needed attention.
Inspectors found significant gaps in staff training. The home's audits had also failed to identify some of the problems found during the inspection. This led to a continued breach of Regulation 17 on good governance.
The overall rating changed from Inadequate to Requires Improvement. The home was no longer in special measures, but CQC said it would ask for an action plan and monitor progress.
Improved safety systems
Care plans and risk assessments were up to date and contained person-centred information. Infection control had also improved and was in line with guidance.
“Infection control procedures had improved and were now robust and in line with guidance.” from the report
Better recruitment
The provider had introduced appropriate pre-employment checks, including checks with the Disclosure and Barring Service. Agency staff checks were also in place.
“Recruitment processes had improved. The provider carried out appropriate pre-employment checks.” from the report
Open management
Inspectors found the management team open to feedback and willing to act quickly on problems. Lessons learned were shared with staff.
“We found the management team to be open and honest during the inspection process.” from the report
Positive communication
People, relatives, staff and professionals were involved through meetings and feedback. Staff made appropriate and timely referrals to healthcare professionals.
“Communication with people, relatives, staff and professionals was good.” from the report
Staff training gaps
needs fixingThere were significant gaps in training in several areas relevant to people's needs. The provider started additional training after inspectors raised the issue, but the training system needed review.
“There were significant gaps in staff training across several areas including oral health, bed rails, pressure area care, catheter care, equality and diversity, falls prevention and GDPR.” from the report
Medicine records
needs fixingMedicine management was generally safe, but instructions and records were not always consistent for medicines given when needed or at variable doses. Monitoring of pain relief patches was also not effective.
“Where medicines were prescribed as 'when required', or with a variable dose, guidance was not always in place, or consistent, as to how these medicines should be used.” from the report
Governance breach
seriousManagement audits had improved but had not identified some of the problems found by inspectors. The provider had therefore not fully identified risks linked to staff training and remained in breach of Regulation 17.
“This failure to identify risk evidenced a continued breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014” from the report
Care plan inconsistencies
minorCare plans had improved, but inspectors found minor inconsistencies, including information about people's capacity to consent to particular decisions.
“There were some minor inconsistences in the care plans, for example around people's capacity to consent to particular decisions.” from the report
- 01Which staff training gaps identified in the report have now been completed, and how do you check that training is kept up to date?
- 02What new records and checks are used for medicines given when required or at variable doses?
- 03How do you record and monitor the application and use of pain relief patches?
- 04What changes have been made so audits identify problems before they affect people's safety?
- 05What progress has been made on the action plan requested by CQC for the Regulation 17 breach?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from previous comprehensive inspections. This explanation was written from the published report of 19 January 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 Woodlands Nursing Home
8 rated inspections over 8 years: the service has improved, from Inadequate to Good.
- June 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2022Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- December 2021Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- April 2020Goodstayed GoodSafe: GoodWell-led: Good
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015Goodup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2015Inadequatestayed InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- May 2015InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- April 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 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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