Woodcote Hall

Updated 25 April 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

This was a targeted inspection to check on a concern we had about staffing and recruitment.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team consisted of one inspector.

Service and service type

Woodcote Hall is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Woodcote Hall is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. A new manager had been in post for six weeks and intended to submit an application to register. We will assess the application when it is received.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 22 March 2023 and ended on 27 March 2023. We visited the location’s service on 22 March 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We used all this information to plan our inspection.

During the inspection

We spoke with 5 people that use the service and 3 relatives. We also spoke with 9 members of staff including the regional manager, the manager, the Human Resources manager, the administrator, senior care assistants and care assistants.

We observed staff providing support to people in the communal areas of the service. We reviewed a range of records. This included 9 staff recruitment files, staff rotas and training records.

Updated 25 April 2023

About the service

Woodcote Hall is a residential care home providing personal care to up to 56 people. The service provides support to people living with dementia and mental health conditions in one adapted building. At the time of our inspection there were 36 people using the service.

People’s experience of using this service and what we found

At our last inspection, improvements were made to the monitoring of people’s risks and preventing and controlling infection. However, we found concerns during this inspection and further improvements were required to help ensure people were protected from known risks to their health and safety and, to ensure improvements could be sustained.

People were not protected from risk of cross infection as staff were not wearing masks, and there was no risk assessment in place prior to them removing the use of masks. People did not always have required risk assessments in place for known risks, and where risk assessments were in place, these were not always being followed.

People’s needs and choices were not always assessed and where they were, staff did not always follow their care plan. The service had some adaptations to meet people’s needs, however further adaptations were required to meet people’s needs.

Improvements made at our last inspection had not been completely embedded and sustained. This meant people’s safety and wellbeing was placed at risk. Whilst the provider had identified areas for improvement, some concerns we found had not been highlighted and action had not been taken to mitigate risks to people.

Improvements had been made and people’s medicines were now managed safely. Improvements were made to the process in place to ensure lessons were learnt when things went wrong, although we found one incident had missed management oversight. People were safeguarded from the risk of abuse, and they were supported by enough staff.

Improvements were made since our last inspection and people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People were supported by staff who were trained to meet their needs. People were supported to eat and drink enough to ensure a healthy diet. The provider worked in partnership with professionals and organisations to meet people’s needs.

Staff and relatives, we spoke with confirmed the manager was approachable. People’s relatives confirmed they were kept informed of any updates or changes to their loved one’s care.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 14 July 2021) and there were breaches of regulation. At this inspection we found the provider remained in breach of regulations.

Why we inspected

We received concerns in relation to the monitoring of people’s risks. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from inadequate to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Woodcote Hall on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment and good governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will return to the home to ensure they have complied with the enforcement actions taken by us. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service is ‘Requires improvement’. However, one Key Question for this service has remained as ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.