13 October 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.
The inspection was completed by one inspector. A second inspector did attend on the first day of inspection for learning purposes.
Service and service type
Woodgrange is a ‘care home’. People in care homes receive accommodation, nursing or personal care as a single package under one contractual agreement dependent on their registration with us. Woodgrange is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
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
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 seven people who used the service and six relatives, to learn about their experiences of the service provided. We spoke with 20 staff members including the registered manager and the regional director. We also received feedback from four health and social care professionals who knew the service.
We reviewed a selection of care records for 11 people including medicine administration records, care plans, risk assessments, daily notes and incident forms. We reviewed eight staff files and records relating to training, recruitment, performance management and support.
We reviewed a selection of records relating to the management and quality monitoring of the service. These included complaint management, accident and incident monitoring, quality audits, meeting minutes and provider oversight. We also reviewed a selection of policies and procedures.
13 October 2022
Woodgrange is a nursing and care home located in Bourne, providing personal and nursing care to up to 64 people. The service has three separate areas that specialise in providing care to people living with dementia, people who require nursing care, and people who have residential care needs. At the time of our inspection there were 51 people using the service.
People’s experience of using this service and what we found
A range of quality assurance systems were in place to monitor and improve the service, however, these were not always used effectively. Some areas of the kitchen were unclean and water outlets had a build-up of limescale. Care staff supported people to eat in a caring and dignified way but did not always wash or sanitise their hands before moving on to support the next person.
Visitors were welcomed throughout the day and relatives told us staff were really friendly and helpful. An effective safeguarding system was in place to ensure people’s safety and people told us they felt safe. Risks relating to people’s individual health and care needs were assessed, and people received their medicines as prescribed. Staff supporting people with food and drink had received the appropriate training. Safe recruitment and background checks were in place and we observed there were enough staff to meet the needs of people using the service.
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.
The registered manager and regional director demonstrated they were focused on meeting positive outcomes for people. The provider held regular meetings to keep people informed of developments and changes to the service. Care plans and assessment processes considered people’s individual characteristics. Staff received regular supervision and attended frequent team meetings. Feedback about the registered manager was consistently positive and the provider worked closely with other health and social care professionals to ensure people received consistent and timely care.
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 25 January 2020).
Why we inspected
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.
The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of specialised dietary requirements and choking risks. This inspection examined those risks. We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the safe and well-led sections of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Woodgrange on our website at www.cqc.org.uk.
We will continue to monitor information we receive about the service, which will help inform when we next inspect.