CQC report explained · a residential care home
What the CQC found at Woodleigh Rest Home Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2023
Rated Requires Improvement and placed in special measures; inspectors found unsafe medicines, risks and leadership, with the well-led rating still Inadequate.
This was an unannounced focused inspection on 19 and 24 January 2023. Inspectors spoke with people, relatives and staff, observed care, looked around the home and checked care, medicine, staff and management records.
The home had not fixed several problems from the previous inspection. Medicines were not checked safely, some risks were not properly assessed or monitored, and people's nutrition and hydration needs were not always met. The home remained in breach of regulations about safe care, nutrition and governance.
There were also improvements. Recruitment checks were completed, staff had received training and supervision, infection control arrangements were mostly satisfactory, and people and relatives generally described staff as kind and said they felt safe.
The overall rating improved from Inadequate to Requires Improvement. However, the home was placed in special measures because at least one key question had been rated Inadequate at two consecutive inspections. The Safe and Effective ratings were Requires Improvement, while Well-led remained Inadequate.
People generally felt safe
Most people and relatives told inspectors they felt safe at the home. Safeguarding systems and staff understanding had improved since the previous inspection.
“People and relatives said they felt safe living at the home.” from the report
Safer recruitment
The required checks had been completed before staff started work.
“Recruitment was managed safely. The required checks had been completed prior to staff starting work.” from the report
Staff training and support
Staff had received mandatory training and supervision. Refresher moving and handling training was provided promptly after inspectors raised concerns.
“Staff had the training and support to carry out their roles.” from the report
Infection control
Inspectors were assured that the home could prevent and manage infection risks in most areas, including the use of protective equipment and support for visitors.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Healthcare support
The home worked with healthcare professionals and supported people to attend appointments.
“People's care records evidenced the involvement of professionals such as the GP, district nurses and mental health professionals.” from the report
Risks were not properly managed
seriousA sensor mat by the staircase did not work, moving and handling guidance was not always followed, and additional checks after falls were not evidenced.
“Risks to people's health and safety were not always managed safely.” from the report
Nutrition and hydration shortfalls
seriousWeekly weight monitoring was missed for some people. One person did not consistently receive the required soft diet, creating a choking risk.
“Where people had been assessed as requiring their weight monitoring weekly this was not always in place.” from the report
Weak leadership and oversight
seriousThe home had no registered manager. Audits did not identify problems found by inspectors, and previous concerns had not been fully resolved.
“Governance processes were not effective. This is the second inspection when the well-led key question has been rated Inadequate.” from the report
Little activity and stimulation
needs fixingInspectors did not see activities being offered. There was no activity coordinator, and staff were mainly focused on daily care needs.
“Over the course of the inspection we did not observe person-centred activities taking place.” from the report
- 01What checks now confirm that controlled drugs and all other medicines are correctly recorded and given as prescribed?
- 02How do you make sure moving and handling plans are followed, including when people need a hoist?
- 03How are falls, additional checks and other accidents recorded, reviewed and acted on?
- 04How do you monitor people's weights and make sure each person receives the correct food and drink consistency?
- 05Who is now managing the home, and what evidence can you show that the governance problems have been fixed?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected, so their ratings carried over from the previous inspection. This explanation was written from the published report of 7 April 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, July 2022
Rated Inadequate and placed in special measures; inspectors found people at risk from unsafe medicines, poor risk management, staffing shortfalls and weak oversight.
This was an unannounced focused inspection on 14, 16 and 27 June 2022. Inspectors spoke with nine people, seven relatives and 10 staff. They looked around the home, observed care and mealtimes, and reviewed care plans, medicines records and other documents.
The inspectors found serious problems with medicines, risk assessments, falls, safety checks, food and fluid monitoring, infection control and staffing. Some people had missed medicines. Records did not always show that care, checks, food and fluids had been provided safely.
Care was not always personal or responsive. Some staff were kind, but others were task-focused. Staff did not always have the training, induction or supervision needed. The home’s audits and management systems had not identified or fixed the problems.
The overall rating was Inadequate. Safe, effective and well-led were also rated Inadequate. The home was placed in special measures, which means the CQC will keep it under review and normally re-inspect within six months.
Emergency plans
Personal Emergency Evacuation Plans were in place and contained information for staff to follow.
“Personal Emergency Evacuation Plans (PEEPs) were in place for people and contained relevant information for staff to follow.” from the report
Mental capacity processes
The report found systems for monitoring Deprivation of Liberty Safeguards applications and authorisations. Capacity assessments and best-interest decisions had also been completed where needed.
“Where people lacked the capacity to make their own choices and decisions, capacity assessments and best interest decisions were completed.” from the report
Visits
The home was facilitating visits in line with the guidance in place at the time.
“We were assured the provider was facilitating visits for people living in the home in accordance with the current guidance.” from the report
Some people felt safe
Despite the safety concerns found by inspectors, people spoken with said they felt safe.
“People told us they felt safe in the service.” from the report
Unsafe medicines
seriousSome people missed doses. Medicines given at specific times were not always given on time, and records had gaps or inaccurate stock information.
“Some people missed doses of their medicines on the first day of the inspection because the registered manager had forgotten to administer them.” from the report
Unmanaged risks
seriousFalls, bed rails, skin care, nutrition, choking and safety checks were not assessed or recorded properly. This left people at risk of avoidable harm.
“We reviewed 12 peoples care plans and risk assessments and found shortfalls in them all.” from the report
Food and fluids
seriousFood and fluid records were incomplete and some people had lost significant weight without timely action or referrals to health professionals.
“People did not have their nutritional and hydration needs met. This was a breach of Regulation 14 (Meeting Nutritional and Hydration Needs)” from the report
Infection control
seriousStaff did not always wear masks correctly, social distancing was not consistent and some areas were not clean. The report also found no evidence of testing people before admission.
“People were not protected from the risk of infection as control measures were not implemented consistently.” from the report
Staff training and recruitment
needs fixingSome staff had not received essential training, induction or supervision. Recruitment files also had important gaps, and staffing levels were not always enough for people’s needs.
“Staff had not received the support, training and supervision necessary for them to carry out their roles.” from the report
Weak management oversight
seriousThe home’s audits did not identify or resolve serious problems. Leadership changed during the inspection, with a manager from a sister home overseeing the service part time.
“We found systems to assess, monitor and improve the service were not sufficiently robust.” from the report
- 01What has changed in the medicines system since the inspection, and how do you check that doses, timings, stock and records are correct?
- 02How are falls, bed rails, pressure care, choking, nutrition and hydration risks now assessed and reviewed?
- 03What staffing levels are currently in place, and how are they calculated against residents’ needs?
- 04Which staff have completed induction, safeguarding, moving and handling and infection control training, and how is this monitored?
- 05What action has been taken in response to the special measures rating and the breaches identified by the CQC?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 23 July 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 Woodleigh Rest Home Limited
6 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- April 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Inadequate
- July 2022Inadequatedown from GoodSafe: InadequateEffective: InadequateWell-led: Inadequate
- June 2019Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Requires improvement
- May 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- November 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 30 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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