CQC report explained · a nursing home
What the CQC found at Woodstock Care Centre
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments and care plans were not always current or detailed enough. Medicines were not always managed safely, although staffing, safeguarding and infection control arrangements were found to be satisfactory.
- Effective?
- Good
- The report does not give a rating or detailed findings for Effective.
- Caring?
- Good
- The report does not give a rating or detailed findings for Caring.
- Responsive?
- Good
- The report does not give a rating or detailed findings for Responsive.
- Well-led?
- Requires improvement
- Quality checks did not identify problems with medicines and risk management. Managers acted quickly when inspectors raised concerns, but CQC wanted to see that improvements became established.
What inspectors found, March 2023
Rated Requires Improvement; inspectors found risks and medicines were not always managed safely, although staffing and infection control were good.
Inspectors visited the home and spoke with people, relatives, managers and care workers. They reviewed care records, staff files and management records. The inspection was unannounced.
The main concerns were about risk assessments, constipation care and medicines. Some records did not contain current, personalised instructions. Inspectors also found missing guidance for some medicines and an inaccurate medicines record.
There were enough staff, recruitment checks were completed and infection control was satisfactory. People and relatives said they felt safe, and staff knew how to report abuse.
The home remains Requires Improvement for Safe and Well-led. The report says improvements had been made since the previous inspection and there were no current breaches, but changes needed to become established. This was the third consecutive Requires Improvement rating.
Enough staff
Inspectors saw enough staff to meet people's care and social needs. Recruitment checks were also completed safely.
“We observed there to be enough staff to meet people's care and social needs during our inspection.” from the report
People felt safe
People and relatives said they felt safe. Staff had safeguarding training and knew how to report concerns.
“People and their relatives told us they felt safe receiving care at the service.” from the report
Clean environment
Inspectors found the home clean, with regular cleaning and suitable infection control equipment available.
“The home was clean and free from odour. We observed regular cleaning taking place throughout our inspection.” from the report
Responsive managers
Managers acted straight away when inspectors identified problems and later sent updated care plans and medicine protocols.
“The management team were receptive of the areas we found during our inspection. They worked straight away to rectify issues found.” from the report
Risk information was incomplete
needs fixingSome risk assessments did not contain current, personalised instructions. This included choking support and constipation care.
“People's individual risks were identified but were not always well managed. Risk assessments did not include relevant information for staff to follow in the event of an emergency.” from the report
Constipation care
seriousTwo people went at least six days without opening their bowels, and staff and the registered manager were unaware. Inspectors found that no action had been taken for one person during six days.
“We identified two people who had gone at least 6 days without opening their bowels. The staff and registered manager were unaware this had happened.” from the report
Medicines records and instructions
seriousSome PRN medicines did not have protocols, and existing protocols lacked clear step-by-step instructions. One medicines record showed more doses than the prescribed maximum, without recording that a dose had been destroyed.
“Medicine administration records (MAR) were not recorded accurately.” from the report
Checks did not find problems
needs fixingAudits had not identified the shortfalls in medicines management and risk records. This led to the continued Requires Improvement rating for well-led.
“Quality assurance systems were in place, however, were not effective in picking up concerns we found on inspection.” from the report
- 01What changes have been made to the care plans for people at risk of choking, and how are staff checked on the correct response?
- 02How do you now identify and respond when someone has not opened their bowels for two days?
- 03Does every PRN medicine have a clear protocol explaining when and how it should be given?
- 04How are medicines records checked to make sure every dose, including destroyed doses, is recorded accurately?
- 05What evidence can you show that audits now identify problems with risk management and medicines?
The report gives ratings only for Safe and Well-led, including infection prevention and control; it does not give ratings for Effective, Caring or Responsive, and it contains two different accounts of the inspection dates. This explanation was written from the published report of 18 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, November 2019
Woodstock Care Centre was rated Requires Improvement because staffing, safeguarding and management systems were not reliable enough.
This was a planned inspection after the previous Requires Improvement rating. Two inspectors visited on 3 and 8 October 2019. The first visit was unannounced and the second was announced. They spoke with people, relatives and staff, observed care, and checked care, medicines, staffing and management records.
The home was rated Good for effective, caring and responsive care. Inspectors found kind relationships, personalised care plans, suitable activities, support with food and drink, and safe medicines management. People were generally treated with dignity and respect.
The home was rated Requires Improvement for safe and well-led care. There were not enough reliable systems to show that staffing matched people's needs. Agency staff did not always know people well, some safeguarding concerns were not reported promptly, incidents were not always used to prevent further harm, and quality checks had missed these problems.
The overall rating stayed Requires Improvement, as it had at the previous inspection. Some improvements had been made, including better staff training and a new manager, but the provider was still in breach of five regulations and needed to make the changes permanent.
Kind and respectful care
Inspectors saw staff treating people with kindness and respecting their privacy, dignity and independence.
“Staff displayed kindness and understanding towards people and addressed them by their preferred names.” from the report
Personalised care
Care plans described people's preferences and how staff should support them. People and relatives were involved in reviewing care.
“People's care plans were personalised and gave staff guidance informing them how the person wanted their care needs met.” from the report
Medicines managed safely
Medicines were stored securely, records were accurate and staff competence was checked.
“MAR sheets were completed accurately and stocks we checked tallied with the balances recorded.” from the report
Good health and nutrition support
The home supported people with balanced meals, drinks, healthcare appointments and referrals when needed.
“People's nutrition and hydration needs had been assessed.” from the report
Activities and relationships
People had a range of activities and were encouraged to stay in contact with people who mattered to them.
“A weekly schedule of activities was available to people such as, singers, arts and crafts, games, religious services and dog visits with the local PAT dog.” from the report
Staffing levels and agency cover
seriousThe home had not assessed how much staff time each person needed. Agency staff did not always know people or their care needs, and six care shifts were not filled when agency workers did not arrive.
“There was a high use of agency staff whilst recruitment for permanent care staff was underway.” from the report
Safeguarding reports
seriousTwo potential safeguarding incidents had not been reported to the local authority until inspectors raised them. This included an incident involving a person hitting another person and missed morning medicines.
“Potential safeguarding concerns had not been consistently reported to the local authority safeguarding team.” from the report
Learning from incidents
seriousAccidents and incidents were not always reviewed properly or used to update care plans. Inspectors saw one person being supported by one staff member even though two were required after a fall.
“Accident and incidents involving people had not always been analysed with action taken to prevent the risk of reoccurrence.” from the report
Management checks
needs fixingQuality monitoring systems had not identified the problems found during the inspection. A new manager had started improvement work, but the changes were not yet established.
“The quality monitoring systems in place had failed to identify the continued shortfalls found during this inspection.” from the report
Required notifications
seriousThe provider had not consistently sent statutory notifications to CQC when significant events happened.
“Statutory notifications had not consistently been submitted to the CQC in line with their regulatory responsibility.” from the report
- 01How do you now calculate the staffing time each resident needs, and what happens when an agency worker does not arrive?
- 02How do you make sure agency staff know each resident's care needs, risks and communication preferences before starting a shift?
- 03What changes have you made to ensure every safeguarding concern is reported promptly to the local authority?
- 04How are falls, missed medicines and other incidents now reviewed, and how do you make sure care plans are updated afterwards?
- 05What evidence can you show that the new quality checks are identifying and fixing problems?
This was a planned inspection covering all five CQC questions, including the premises and care provided; it followed the previous Requires Improvement rating. This explanation was written from the published report of 26 November 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.
Every inspection of Woodstock Care Centre
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- October 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2017Goodstayed GoodEffective: Good
- August 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 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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