Woodrow Retirement Home Limited

Updated 1 June 2022

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.

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 was made up of one inspector and an assistant inspector.

Service and service type

Woodrow Retirement Home 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. Woodrow Retirement Home 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 service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

Before the inspection we reviewed information, we held about the service including notifications we had received. We used the information sent to us in the Provider Information Return. This is information providers are required to send us with key information about their service, what they do well and improvements they plan to make. This information helps support our inspections.

We used information gathered as part of monitoring activity that took place on 6 April 2022 to help plan the inspection and inform our judgements. We used all this information to plan our inspection.

During the inspection

We spoke with the provider who was also the registered manager, the head of care and six care staff. We spoke with four people who used the service and four relatives. We also spoke with one visiting healthcare professional.

We reviewed a range of records. This included eight care records and four medicine records. We looked at four staff files in relation to recruitment and management records.

After the inspection

We requested records in relation to governance such as audits and checks along with staff training. We continued to seek clarification from the provider to validate evidence found.

Updated 1 June 2022

Woodrow is a residential care home providing accommodation and personal care for up to 18 people. At the time of our inspection 15 people were using the service.

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

Quality assurance processes and checks were not always in place or effective and had not identified the concerns raised during the inspection.

People’s medicines were not always managed in a safe way. Medicine recording systems did not demonstrate people received their medicines as prescribed.

People were not always protected by safe recruitment procedures.

People’s capacity had not been assessed following the principles of the Mental Capacity Act 2005 (MCA).

People’s care and risk assessment records were not always reflective of people’s care and support requirements. However, staff demonstrated a good awareness and understanding of people’s individual needs.

People, their relatives and staff spoke highly of the management team. Feedback was positive about staffs’ approach and understanding of people’s care and support needs.

The provider failed to notify us of incidents that happened in the service as is required by law.

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

Rating at last inspection

The last rating for this service was good (published 3 February 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

Concerns were identified. As a result, we undertook a focussed inspection to review the key questions of safe and well-led. 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 good to requires improvement based on the findings of this inspection.

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.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this report.

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

Enforcement

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.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider to discuss how they will make changes to ensure they improve their rating to at least good. We will also continue to monitor information we receive about the service, which will help inform when we next inspect.