CQC report explained · a residential care home
What the CQC found at Woodmarket House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- Inspectors found that people were protected from abuse and avoidable harm. Medicines, staffing, infection control and incident management were judged safe.
- Effective?
- Requires improvement
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Caring?
- Requires improvement
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Responsive?
- Requires improvement
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- The home had systems for audits, staff support and monitoring, but earlier environmental concerns had not been fully addressed and there were no clear timescales for completing the work.
What inspectors found, October 2020
Requires Improvement; inspectors found safe care, but unfinished environmental work meant leadership and oversight still needed improvement.
This was a focused inspection on 11 August 2020. Inspectors looked only at Safe and Well-led, spoke with staff, relatives and the manager, and checked care, medicine, recruitment and management records.
The home was rated Good for Safe. Inspectors found safe medicines, suitable staffing, infection control measures and systems for managing incidents and falls. Falls had reduced by 50% over the previous three months.
The home was rated Requires Improvement for Well-led, the same as at the previous inspection. Environmental work was still unfinished, including window frames and scuffed doors, and there were no clear timescales for completing all the work.
The overall rating stayed Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were used in calculating the overall rating.
Safe medicines
Inspectors found that medicines were stored, received and disposed of safely, and people received them as prescribed.
“Medicines were managed safely, and people received their medicines as prescribed.” from the report
Fall prevention
The home recorded and reviewed incidents, put prevention measures in place and had reduced falls noticeably.
“There had been a noticeable decrease in falls with a 50 percent reduction in the last 3 months.” from the report
Infection control
The home followed current COVID-19 guidance. Staff had protective equipment and relevant infection control training.
“Staff had access to, and were seen to use, protective clothing such as aprons, gloves and masks.” from the report
Safeguarding
Staff understood how to protect people from abuse and how to report concerns.
“Staff were able to explain their role in safeguarding vulnerable adults and could tell us what they would do in the event of any concerns.” from the report
Unfinished maintenance
needs fixingThe home had not completed its earlier environmental action plan. Window frames and scuffed doors still needed attention, with no clear completion dates.
“However, it has not fulfilled its action plan and maintenance issues still require immediate attention this included replacing window frames and scuffed doors.” from the report
Incomplete analysis of distressed behaviour
needs fixingThe manager was still developing a system to analyse when distressed behaviour happened. Inspectors said this meant the full impact could not yet be assessed and all preventative measures could not be put in place.
“As this exercise had not been fully completed the impact on people could not be fully assessed, therefore full preventative measures could not be put in place.” from the report
- 01Which window frames and other maintenance issues are still outstanding, and what are the dates for completing each one?
- 02How are you now analysing distressed behaviour and checking that preventative measures are working?
- 03What changes have been made since this inspection to improve the Well-led rating?
- 04What were the previous ratings for Effective, Caring and Responsive, which were not inspected during this visit?
- 05How will residents and relatives be kept informed about progress with the maintenance action plan?
This was a focused inspection of Safe and Well-led only; the other three ratings carried over from previous comprehensive inspections. This explanation was written from the published report of 24 October 2020 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 2020
Woodmarket House was rated Requires Improvement; safety and medicines management improved, but some hazards and building problems remained.
This was an unannounced focused inspection on 6 February 2020. Two inspectors reviewed information, spoke with three people using the service and seven staff, and checked care, medicines, recruitment and management records.
The home had acted on a previous warning notice about safe care and treatment. Inspectors found better incident checks, enough staff, safer medicines management and improved safeguarding arrangements. They said all requirements of the warning notice had been met.
Some safety problems remained. A window restrictor was not properly fixed and an electrical lead created a trip hazard. The home also had several maintenance and decoration problems, including damp, water damage and damaged surfaces.
The overall rating remained Requires Improvement. Safe improved from Inadequate to Requires Improvement, while Well-led remained Requires Improvement. The other three areas were not assessed during this focused inspection.
Safer care
Incident reviews had improved and managers investigated accidents to reduce the chance of them happening again. Staff also used measures such as motion sensors and worked with health professionals to reduce falls.
“Analysis was carried out to find out why the accident occurred and what could be put in place to reduce further risk.” from the report
Enough staff
Inspectors found staffing numbers and skills were sufficient. The home had also arranged another agency provider to help cover short-notice absences.
“Staffing numbers and skill mix were sufficient to meet people's needs.” from the report
Medicines management
Medicines records were accurate and up to date. Medicines were reviewed, staff training and checks were in place, and audits were carried out.
“Records were maintained for the receipt, administration and return of medicines and these were accurate and up to date.” from the report
Listening to people
The home changed meal times and medicine routines in response to people's views. Staff also involved people in developing the service.
“Changes to day to day routines were made to suit the needs of people who used the service.” from the report
Room safety hazards
seriousInspectors found a window restrictor that was not properly fixed and a trailing electrical lead. They said these had not been identified by the home's checks.
“The window restrictor in one person's room was not properly fixed to the window. There was a trailing electrical lead in one person's room which presented a trip hazard.” from the report
Unfinished maintenance
needs fixingThere were several problems with the building, including damp, water damage, dirty windows, damaged doors and worn flooring. The home had an action plan but no definite completion dates.
“There were no definite timescales in place at the time of our visit.” from the report
- 01When will the window restrictor and trailing electrical lead identified by inspectors be fixed or removed?
- 02What are the definite dates for completing the damp, water damage, damaged doors and worn flooring repairs?
- 03How are you checking residents' rooms for hazards between inspections?
- 04How do you make sure there are enough trained staff when someone is absent at short notice?
- 05What changes have been made since the previous inspection, and how will you show that they are lasting?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not assessed and the overall rating remained based on the wider inspection position. This explanation was written from the published report of 19 March 2020 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 Woodmarket House
5 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- October 2020Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- November 2019Requires improvementdown from GoodSafe: InadequateWell-led: Requires improvement
- February 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2013
Report published without a new overall rating.
- September 2012
Registered with the Care Quality Commission on 28 September 2012.
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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