CQC report explained · a residential care home
What the CQC found at Woodleigh
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and their individual risks were reviewed. Medicines were administered by trained staff, although inspectors said extra staff support would have been helpful over lunch.
- Effective?
- Good
- Staff training, supervision and induction were well managed. People received appropriate healthcare support, had choices about food and care, and were supported in line with the Mental Capacity Act.
- Caring?
- Good
- Staff provided kind, compassionate and dignified care. People were involved in care planning, treated with respect and supported to remain independent.
- Responsive?
- Good
- Care was personalised to people's needs, preferences and communication needs. Activities were available, complaints processes were in place and end of life care reflected people's wishes.
- Well-led?
- Good
- Managers had effective oversight of care, incidents and staff training. Quality monitoring was strengthened during the inspection, and this rating improved from Requires Improvement at the previous inspection.
What inspectors found, August 2019
Rated Good; inspectors found kind, personalised care, with some improvements still needed in staff deployment and environmental risk checks.
This was an unannounced planned inspection on 18 and 23 July 2019. Inspectors spoke with people living in the home, relatives, staff and a healthcare professional. They also reviewed care records, medicines records, recruitment files and quality monitoring records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People were protected from abuse, received their medicines safely and had their risks reviewed. Staff were trained and supported, and people received help with healthcare, food, communication and personal choices.
Inspectors saw kind, respectful care. Activities were based on people's interests, and complaints were recorded and reviewed. Some issues were identified around staff deployment at busy times, environmental risk checks and infection control improvements, but managers responded during the inspection.
The overall rating stayed Good, as it was at the previous inspection. The Well-led rating improved from Requires Improvement to Good.
Kind and respectful care
Inspectors observed compassionate care, and people and relatives gave positive feedback about how staff treated them.
“Staff were observed providing person-centred, respectful and compassionate care.” from the report
Safe medicines support
Medicines were managed by trained staff. Records, temperature checks, audits and support plans were in place.
“Medication practices and procedures were followed by trained members of staff.” from the report
Personalised support
Care plans reflected people's needs and preferences. Staff knew people well and supported choice and independence.
“People received personalised care that was relevant and consistent with their current support needs.” from the report
Improved leadership
The Well-led rating improved from Requires Improvement to Good. Managers used audits and action plans to monitor and improve care.
“Areas of improvement were clearly addressed, and action plans demonstrated improvements that had been made.” from the report
Staff deployment at busy times
needs fixingStaffing levels appeared well managed overall, but inspectors said staff deployment needed attention, especially around lunchtime.
“over the lunch time period, extra staff support would have been beneficial.” from the report
Environmental risk checks
needs fixingInspectors identified areas for improvement in managing risks inside and outside the home. Managers responded by putting regular assessment measures in place.
“We noted some areas of development in relation to environmental risk management.” from the report
Infection control improvements
minorCleaning schedules and an infection control policy were in place, but the action plan still identified areas needing improvement.
“The infection control action plan identified areas needed for improvement.” from the report
- 01How are staff deployed during busy periods, particularly at lunchtime?
- 02What changes were made to assess and manage risks in the indoor and outdoor areas?
- 03Which improvements remained on the infection control action plan, and have they now been completed?
- 04How are people's individual care plans and risk assessments reviewed when their needs change?
- 05How are activities matched to each person's interests, preferences and communication needs?
This was an unannounced planned inspection covering all five key questions and the overall quality and safety of care. This explanation was written from the published report of 23 August 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.
What inspectors found, January 2017
Rated Good overall; inspectors found kind, safe and personalised care, but leadership and reporting systems required improvement.
This was an announced inspection on 22, 23 and 26 August 2016. It was the first inspection since the provider changed in March 2015. Inspectors spoke with people, relatives, staff and health professionals, and reviewed care files, staff records, complaints, safeguarding records, rotas and audits.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found that people were treated with kindness and dignity, received personalised care, had suitable food and activities, and could access health professionals. Medicines, recruitment and risk management were also found to be safe.
The home was rated Requires Improvement for Well-led. There was no registered manager in day-to-day charge, and safeguarding incidents had not been notified to the CQC. Some policies, audits and records were still being developed. The overall rating was Good because the four other areas were rated Good.
Kind and respectful care
Staff were observed treating people with dignity and kindness. Inspectors saw positive relationships and staff who understood people's individual preferences.
“We observed staff treated people with dignity, respect and kindness.” from the report
Personalised support
Care plans described people's needs, preferred routines and personal choices in detail. Risks were assessed and plans were reviewed.
“Care plans viewed were person centred.” from the report
Safe medicines
Staff who gave medicines were trained and assessed as competent. Medicines were stored, administered and recorded satisfactorily.
“People were protected from the risks associated with unsafe medicines management.” from the report
Activities and social contact
People could join individual and group activities, including music, outings, crafts and social events. Inspectors saw people enjoying activities and interacting with staff.
“People were observed to engage in and enjoy the activities provided” from the report
Food and nutrition
Menus offered choices and a varied, balanced diet. The kitchen was clean and organised, and the food standards inspection had awarded the highest rating.
“Woodleigh was awarded a rating of 5 stars which is the highest award that can be given.” from the report
No registered manager
needs fixingThere was no registered manager providing day-to-day leadership when inspectors visited. Four area coordinators were sharing management duties while a new manager was awaited.
“The service did not have a registered manager in place at Woodleigh to provide overall day-to-day leadership and direction.” from the report
Safeguarding notifications
needs fixingThe provider had not notified the CQC about incidents or suspected abuse, despite records showing safeguarding referrals had been made to the local authority. The CQC wrote to the provider about this failure.
“We noted that the provider had not notified the CQC of any incidents or allegations of abuse in relation to people using the service.” from the report
Audits and policies still developing
needs fixingSome policies, records and audit tools were not yet consistent. Incident and medicines logs did not identify lessons to be learned.
“We noted that the reports did not identify lessons to be learnt.” from the report
Weekend staffing concerns
minorThree relatives were concerned about the use of agency staff, particularly at weekends. Inspectors shared this feedback with the management team.
“I notice staff shortages some weekends. I know this is difficult to resolve.” from the report
Contact and booking arrangements
minorSome relatives found the new short-term-break booking process confusing. A temporary mobile phone also caused anxiety because families were waiting for a direct line.
“This was causing some anxiety among a few relatives who were eager to be provided with a direct line as soon as possible.” from the report
- 01Is there now a registered manager in day-to-day charge of the home?
- 02How are safeguarding incidents and suspected abuse reported to the CQC and the local authority?
- 03What changes have been made to audits so that incidents and medicines errors lead to recorded lessons and action?
- 04How do you manage agency staffing at weekends, and how do you make sure enough familiar staff are available?
- 05What is the current process for booking short-term breaks, and what direct telephone number can families use?
This was an announced inspection of the overall service and all five key questions, following a change of provider; the report also covers short-term breaks and supported living services coordinated from the premises. This explanation was written from the published report of 25 January 2017 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
2 rated inspections over 3 years: the service has held its Good rating throughout.
- August 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2015
Registered with the Care Quality Commission on 2 March 2015.
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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