CQC report explained · a residential care home
What the CQC found at Woodthorne Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, safe medicines practices, infection control measures and staff who understood people's individual risks.
- Effective?
- Good
- This key question was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- Management systems did not always identify shortfalls or record the action taken. Some care plans lacked important details, and not all recommendations from external agencies had been acted on.
What inspectors found, August 2021
Rated Good overall; inspectors found safe care, but the home's leadership and record keeping still needed improvement.
This was an unannounced, focused inspection on 29 June 2021. Inspectors looked only at Safe and Well-led because concerns had been raised about records and plans for a day centre. They spoke with people, relatives, staff and a health professional, and reviewed care, medicine, staffing and management records.
Safe was rated Good. Inspectors found enough staff, safe medicines practices, suitable infection control measures and staff who understood people's risks and how to report abuse. They found no evidence that people had been harmed because of the concerns examined.
Well-led was rated Requires Improvement. Audits did not always record what action had been taken, and some care plans did not contain enough detail for staff to support people consistently. The overall rating remained Good, partly because the other three key questions were not inspected and their previous ratings were carried forward.
Enough staff
People, relatives and staff said there were enough staff. Inspectors saw staff respond promptly and spend time with people.
“There is always someone here. I am never on my own.” from the report
Safe medicines
Staff supported people to take medicines safely. Records showed medicines had been given as prescribed, with guidance for medicines given when needed.
“Medication administration records (MARs) showed people had been given their medicine as prescribed.” from the report
Infection control
Inspectors were assured that the home had measures for PPE, testing, social distancing, visiting and managing infection outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Staff support
Staff said they felt supported. They received regular supervision and could get help from managers.
“Staff received regular supervisions with managers to discuss their role and gain additional support where required.” from the report
Audit actions were not always recorded
needs fixingAudits identified some improvements, but the records did not always show what action had been taken or who was responsible.
“Where audits had identified areas for improvement, it was not always recorded what action had been taken in response to these findings.” from the report
Care plans lacked detail
needs fixingSome care plans did not explain fully how staff should manage identified risks. Staff knew people well, but the written records needed updating.
“Some care plans did not provide detailed information to staff on how they should support people with identified risks to safety.” from the report
Day centre plans needed checking
needs fixingThe provider planned to allow people from the community to use communal areas. Inspectors wanted to see a risk assessment covering how people living in the home would be kept safe.
“The provider gave assurances they would share a risk assessment with CQC around this.” from the report
External recommendations not all acted on
needs fixingThe provider had not acted on some recommendations from an external agency about the detail in care records. The provider planned to discuss this with the agency.
“The provider acknowledged they had not acted on some of the recommendations made and planned to liaise with the external agency about this.” from the report
- 01Have all care plans been updated to explain clearly how staff should manage each person's risks?
- 02How do you now record actions from audits, including who is responsible and when actions must be completed?
- 03What risk assessment is in place for the planned day centre and can families see how people living in the home will be protected?
- 04What action has been taken on the recommendations from the external agency about care records?
- 05How will you check that improvements to records are maintained over time?
This was a focused inspection of Safe and Well-led only; the other three ratings were not inspected and previous ratings were used in calculating the overall rating. This explanation was written from the published report of 7 August 2021 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, February 2020
Rated Good overall; inspectors found safe, kind and responsive care, but management checks still needed improvement.
The inspection took place on 20 and 25 November 2019. One inspector spoke with people living at the home, relatives, staff and the provider. They observed care, checked care and medicine records, and reviewed staff files, training and service records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found that people were protected from harm, received their medicines safely, had their needs met and were treated with kindness and respect. Improvements had been made since the previous inspection, including better risk assessments, medicine management and activities.
Well-led was rated Requires Improvement. Some records and checks were not completed consistently, including records of notifications and call bell response times. The overall rating improved from Requires Improvement at the previous inspection to Good.
People were kept safe
Inspectors found that risks were assessed and managed appropriately. Staff understood safeguarding procedures, recruitment checks were completed, and there were enough staff on duty.
“People were kept safe and secure from risk of harm.” from the report
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw caring interactions and found that privacy, dignity and personal choices were respected.
“People were treated with kindness and compassion. People's right to privacy was respected by the staff who supported them and their dignity was maintained.” from the report
Personalised support
Staff knew people well and supported their individual needs, preferences, cultural dietary requirements and health needs. People and relatives were involved in care planning.
“People received personalised care that was responsive to their needs.” from the report
Improvements since the last inspection
The home had acted on earlier concerns about risk assessments, medicines, recording and activities. Safe and Responsive improved from Requires Improvement to Good.
“At this inspection we saw that significant improvement had been made.” from the report
Some management records were incomplete
needs fixingAudits did not always give a consistent picture of the service. Notifications had been sent to CQC correctly but were not recorded in the audit file, and call bell response times were not always recorded.
“Recording of call bell response times were also not consistently recorded.” from the report
- 01How are you now making sure call bell response times are recorded every time?
- 02How do you check that all CQC notifications are included in the audit records?
- 03What action has been taken to improve the Well-led rating since this inspection?
- 04How are risk assessments and medicine records checked to make sure the improvements found at this inspection continue?
- 05How are activities planned and reviewed for each person's individual interests?
This was a planned inspection covering all five CQC key questions; Safe and Responsive improved to Good, while Well-led remained Requires Improvement. This explanation was written from the published report of 19 February 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 Woodthorne Care Home
5 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- August 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2020Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- November 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 15 December 2010.
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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