CQC report explained · a nursing home
What the CQC found at Woodstock Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2023
Rated Requires Improvement; inspectors found safe staffing levels and caring support, but recruitment checks and quality monitoring were not reliable enough.
This was an unannounced focused inspection. Inspectors visited on 14 and 15 March 2023, with inspection activity continuing until 17 March. They spoke with people living in the home, relatives and staff, and checked care records, medicines, recruitment files, audits and infection control arrangements.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were also rated Requires Improvement. Staff numbers appeared sufficient, medicines were managed safely, risks were assessed and the home was clean. However, some staff recruitment checks were incomplete, and consent was not always recorded before movement sensors were used.
The home's monitoring systems had not found several of these problems. Inspectors also found gaps in infection control audits, delays in some call bell responses and no recorded actions when falls increased. The provider must send an action plan, and the CQC will monitor progress.
Staff available
Inspectors saw enough staff available to supervise people and meet their care and social needs during the inspection.
“At the time of the inspection, we observed staff to be available to supervise people and to meet their needs as required.” from the report
Medicines managed safely
People received their medicines as prescribed. The home had also taken action to improve the availability of medicines.
“People's medicines were managed safely, and they received the support they needed to take their medicines as prescribed.” from the report
Good health support
People were referred to healthcare professionals when needed and received support with appointments, nutrition, falls and other health needs.
“Staff worked closely with health care professionals to ensure the right care and treatment was provided.” from the report
Positive communication
Inspectors saw staff use different ways of communicating with people, including gestures and simple questions, to help people express their views.
“We observed staff communicating in a positive and supportive way with people, to help them feel involved and reassured.” from the report
Incomplete recruitment checks
seriousSome required checks on applicants' previous care work, employment gaps and references were not completed or clearly recorded before staff started work.
“The required staff recruitment checks were not always completed.” from the report
Consent records
needs fixingMovement sensors were used for some people without consent being recorded or relatives being consulted where needed. Inspectors said care records did not always show that the least restrictive option had been chosen.
“Care records needed to improve in this respect, to demonstrate the least restrictive option/s had been adopted and decisions made on behalf of people were in their best interests.” from the report
Weak quality monitoring
seriousThe provider's audits had not identified important shortfalls. This included missing infection control audits, unexplained call bell delays and a lack of recorded action when falls increased.
“The provider's systems and processes for assessing, monitoring and improving the quality and safety of the services had not always been effective in identifying shortfalls and addressing these.” from the report
Call bell delays
needs fixingIn the records checked, 11 of 27 call bells took seven minutes or more to answer. The records did not explain the delays or set out actions to improve response times.
“Call bell response times for 11 out of 27 calls were recorded as taking 7 minutes or more to answer.” from the report
- 01Have all staff recruitment checks, references and employment history checks now been completed and recorded?
- 02How do you obtain and record consent before using bedroom movement sensors or other supervision and control equipment?
- 03What action has been taken after the recorded delays in answering call bells?
- 04How are increased falls now reviewed, and what changes are made to reduce the risk of further falls?
- 05How often are infection control audits completed, and how do managers check that no audits are missed?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward when calculating the overall rating. This explanation was written from the published report of 16 June 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, January 2020
Rated Good overall; inspectors found safe, kind and responsive care, but consent and least-restrictive practice required improvement.
This was an unannounced inspection over 4, 5 and 6 December 2019. One inspector spoke with people, relatives, staff and health professionals. They also observed care and reviewed care plans, staff files and other records.
The home was rated Good overall. Safe, Caring, Responsive and Well-led were rated Good. Effective was rated Requires Improvement because the home did not always follow the legal process for consent and restrictive care.
People were described as safe and treated with kindness and respect. Inspectors found safe medicines management, suitable staff training, personalised care plans, activities and access to health professionals. They also found a lack of clear signage for people living with dementia.
The overall rating remained Good, as it was at the previous inspection published in May 2017. Safe improved from Requires Improvement to Good, while Effective fell from Good to Requires Improvement.
Safe care and medicines
Inspectors found that risks were assessed, staff were recruited safely and medicines were managed consistently.
“Medicines systems were organised, people consistently received their medicines when they should.” from the report
Kind and respectful staff
People and relatives said staff treated them with kindness, dignity and respect. Staff supported people's choices and independence.
“People told us they liked the staff and were happy with the care they received.” from the report
Personalised care
Care plans reflected people's individual needs, preferences and communication styles. Relatives said staff knew people well.
“Peoples care plans were specific to them and set out how they would like their needs to be met.” from the report
Activities and relationships
People were supported to take part in activities, build friendships and keep in touch with relatives and the local community.
“People were supported to maintain relationships with their relatives and local community.” from the report
Open management
Staff and relatives said the manager was approachable. The home sought feedback and held meetings with residents and relatives.
“The service regularly sought feedback from people, their relatives and staff members.” from the report
Consent for restrictive care
seriousSome consent forms had been signed by next of kin for restrictive measures, although next of kin did not have legal authority to give this consent. One person had a sensor alarm without a mental capacity assessment or best-interest decision.
“We saw consent forms in people's files that were signed by their next of Kin.” from the report
Limited dementia signage
minorThere was not enough signage to help people living with dementia navigate the home independently. The manager said there had not previously been problems and did not plan improvements at that time.
“We saw there was a lack of signage to assist people to navigate the service.” from the report
Audits missed a legal practice concern
needs fixingThe home's audits did not identify the problems inspectors found with Mental Capacity Act practice. The manager said the relevant assessments would be reviewed.
“However, these audits did not identify concerns we found regarding the mental capacity act.” from the report
- 01Have you completed the review of every person's mental capacity assessments and best-interest decisions?
- 02How do you now obtain lawful consent for sensor mats, bed rails and covert medicines?
- 03What changes have you made to signage for people living with dementia since the inspection?
- 04How do your audits now check that Mental Capacity Act requirements are being followed?
- 05How will you involve the person and their family in care planning and decisions about restrictive measures?
This was an unannounced comprehensive inspection covering all five CQC questions, with the previous ratings reviewed rather than carried over unchanged. This explanation was written from the published report of 21 January 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 Woodstock Nursing Home
5 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- June 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2020Goodstayed GoodSafe: GoodEffective: Requires improvementWell-led: Good
- May 2017Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2015Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2014
Registered with the Care Quality Commission on 2 October 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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