CQC report explained · a residential care home
What the CQC found at Woodrow Cottage
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found medicines records were not always accurate, some health and safety checks in the annex were missing, and there had been safeguarding concerns about the annex. They found enough staff after changes were made there.
- Effective?
- Requires improvement
- Most care plans were detailed, but some were inconsistent or lacked important information. Agency staff induction records in the annex did not always show that all required points had been covered.
- Caring?
- Requires improvement
- Inspectors saw positive communication and a calm atmosphere, especially in the main house. However, some language in care documents and about people was not respectful, and care in the annex had not always promoted dignity and human rights.
- Responsive?
- Requires improvement
- People were supported with communication, activities, healthcare and family contact. However, support in the annex had not always met the person's needs, and some records did not clearly show whether planned activities had taken place.
- Well-led?
- Requires improvement
- The provider had audits and action plans, but its systems did not identify important gaps in care plans and medicines records. Inspectors found a breach because quality and safety were not being assessed, monitored and improved effectively.
What inspectors found, March 2023
Woodrow Cottage is rated Requires Improvement; inspectors found caring staff and some good support, but concerns about medicines, records and care in the annex.
Inspectors visited unannounced on 23 and 24 November 2022. They spoke with people, staff, the manager, relatives and health and social care professionals. They observed care and checked care plans, medicines records, staff files, training, risk assessments and quality checks.
The home was not always safe, effective, caring, responsive or well-led. Inspectors found inaccurate medicines records, gaps in care planning and health and safety checks, and care in the annex that had not always protected the person's dignity, rights, safety or quality of life.
There were also positive findings. Staff knew people in the main house well, used different communication methods and supported people with healthcare, meals, activities and family contact. Changes had been made to staffing in the annex shortly before the inspection, and inspectors found no evidence that people were still at risk from the concern that prompted those changes.
The overall rating Requires Improvement means the home was not consistently meeting the expected standard. The provider breached Regulation 17 on good governance and must send an action plan. CQC said it would monitor progress with the provider and local authority.
Staff knew people well
Staff in the main house understood people's moods, health needs, activities and preferred support. Inspectors saw positive interactions and relatives gave positive feedback.
“Staff demonstrated knowledge of the people they supported in the main house, discussing each person in relation to the kind of day they were having, their moods, activities, health and well being.” from the report
Support with health
People attended health appointments and had support from health professionals when needed. Relatives and professionals said health concerns were followed up.
“People received health appointments including dental services, sight and hearing checks and hospital passports were in place.” from the report
Communication support
Staff used pictures, photographs, verbal communication and sign language. Communication information was available to help staff support people in their preferred way.
“Staff used pictures and photographs as well as verbal communication and sign language to inform people about things like meals and activities.” from the report
Food and family contact
People chose meals, were supported to shop for food and were given time to eat. People also had family contacts and regularly went to family homes at weekends.
“We saw people receiving meals that they enjoyed and had chosen. People were given time and encouragement to eat.” from the report
Medicines records
needs fixingRecords did not always accurately show medicines received, given or disposed of. Inspectors found gaps in medicine administration records and a stock discrepancy.
“However, accurate records were not always maintained of medicines received into the service, administered and disposed of.” from the report
Care in the annex
seriousBefore new arrangements started, the person in the annex had not always received safe, dignified or person-centred care. Inspectors noted concerns about restrictive responses, staffing continuity and quality of life.
“The service had not provided person centred support and achieved good outcomes for the person living in the annex.” from the report
Incomplete care planning
needs fixingSome care plans did not explain important decisions clearly or give enough information about communication, independence and longer-term goals.
“However, some care plan documentation was inconsistent or lacked information.” from the report
Weak quality checks
seriousThe provider's audits did not identify important gaps in care plans and medicines records. This led to a breach of Regulation 17.
“The recent audits had not highlighted inconsistencies and gaps in records including care plans and medicine management.” from the report
Respectful language and dignity
needs fixingSome language used in care documents and about people was not respectful. Inspectors also saw one person left in a lounge while maintenance work was taking place without staff communication.
“Language used in the care documents and about people was not always respectful.” from the report
- 01What medicines recording checks are now in place, and can you show how gaps or stock discrepancies are found and corrected?
- 02Will the person be supported in the main house or the annex, and what staffing arrangements and agency involvement apply there now?
- 03What changes have been made to ensure care plans explain restrictions, communication needs, independence goals and longer-term outcomes?
- 04How do you check that staff use respectful language and protect people's dignity in everyday care?
- 05What action has been taken in response to the Regulation 17 breach, and what progress has been made against the action plan?
This inspection considered all five key questions and infection prevention and control, and was prompted partly by concerns about care provided to a person living in the annex. This explanation was written from the published report of 7 March 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, September 2022
Requires Improvement; inspectors found concerns about staffing, leadership and people’s access to activities.
This was an announced, focused inspection on 28 June 2022. Inspectors looked only at Safe and Well-led after concerns about staffing, leadership and culture. They reviewed records, observed staff, spoke with managers and asked staff for feedback.
The home was not always able to show that enough suitably skilled and experienced staff were working at all times. Staff and a relative raised concerns about staffing levels, agency workers and people not always receiving their funded one-to-two support.
There were positive findings. Medicines were managed safely, recruitment checks were in place, infection control was effective, and care plans and risk assessments helped staff support people safely. However, inspectors found concerns about the culture, leadership changes and how feedback was handled.
The overall rating fell from Good to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected at this visit, so their previous ratings were used.
Medicines
People’s medicines were managed safely. Records showed medicines received, given and disposed of were recorded accurately.
“People could be confident that medicines were managed safely and administered by competent staff” from the report
Risk planning
Personalised risk assessments gave staff guidance on how to support people safely, including when behaviours might challenge others.
“Personalised risk assessments promoted people's safety and reduced risks for people as much as possible.” from the report
Safeguarding
Staff had safeguarding training and could explain how to recognise and report possible abuse.
“Staff were aware of their responsibilities in relation to safeguarding.” from the report
Infection control
Inspectors were assured that the home used suitable infection prevention measures, including safe use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Recruitment checks
The home had the required recruitment records and completed criminal record checks before staff started work.
“A Disclosure and Barring Service (DBS) check had been obtained by the provider before people commenced work at the home.” from the report
Staffing levels and skills
seriousInspectors could not be assured that enough suitably trained and experienced staff were available at all times. Rotas showed several uncovered shifts, and concerns were raised about weekends without enough staff trained in managing aggression.
“We could not be assured there were enough experienced and appropriately trained staff deployed at all times to meet people's needs safely.” from the report
Support not always provided as planned
seriousA relative said their loved one did not always receive the two-to-one support they were funded for. Agency staff who did not know people well were also reported to have caused difficulties.
“they were not always receiving the 2:1 support they were funded for.” from the report
Leadership stability
needs fixingThere was no registered manager at the inspection, and four temporary managers had been in post since the previous registered manager left. Staff views of senior leadership were mixed.
“Prior to our inspection we were informed there had been four temporary managers since the registered manager left in September 2021.” from the report
Culture and feedback
needs fixingStaff said concerns were not always taken seriously or dealt with constructively. The home had not provided evidence of quality surveys for staff, relatives and professionals.
“Staff told us they felt their concerns were not always taken seriously or that appropriate actions had been taken when issues had been raised.” from the report
Activities and community access
needs fixingStaffing and a lack of drivers restricted people’s access to the local community and chosen activities. Relatives said activities were not always available regularly.
“people were not able to access their chosen activities on a regular basis and therefore restricting their quality of life.” from the report
- 01How many permanent and agency staff are currently working, and how do you make sure each shift has enough suitably trained staff?
- 02How will you ensure people receive their planned two-to-one support at all times?
- 03What training do agency and permanent staff have for managing behaviours that may challenge others, including at weekends?
- 04Who is the registered manager now, and what progress has been made with the new manager’s application?
- 05How are you making sure people can take part in their chosen activities and access the local community?
This was a focused inspection of Safe and Well-led only; the other three ratings carried over from the previous comprehensive inspection in 2019. This explanation was written from the published report of 21 September 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 Woodrow Cottage
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- July 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- October 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Registered with the Care Quality Commission on 7 July 2014.
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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These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,260 a week. 23 can care for a couple. 14 years' experience on average.
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