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We are carrying out a review of quality at Woodthorpe Lodge. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 5 August 2020

About the service

Woodthorpe Lodge is a care home registered to provide personal care for up to eight people who may have a learning disability or a mental health condition. There were seven people living in the home at the time of our inspection. However, one person was on extended home leave.

Woodthorpe Lodge is purpose built and the accommodation is all on the ground floor. The service did not fully apply the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

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

People were not always protected from the risk of avoidable harm or abuse because the systems and processes in place to safeguard people were not effective. The provider’s incident management policies and procedures were not routinely followed. Opportunities to learn from incidents were missed. There was a closed culture where staff were reluctant to use the provider’s whistle blowing procedure.

Risks associated with people’s individual needs lacked detailed guidance for staff to effectively manage and reduce risks. Support plans and risk assessments had not been reviewed at the frequency the provider expected.

Staff lacked specific training in some areas and refresher training had not been kept up to date. The environment had not always effectively met people’s needs and ensured their safety. Staff had not received opportunities to discuss their work, development and training needs.

There was not a registered manager. There was a delay in the covering management team having access to key documents to effectively monitor the service and review incidents that had occurred.

The provider’s initial response to concerns raised about increased risk, closed culture and governance was limited. However, following our inspection the provider took immediate action and made improvements to our greatest concerns about safety.

Infection prevention and control procedures reflected Covid-19 pandemic. However, individual support plans and risk assessments in relation to Covid-19 had not been completed. This meant people were put at increased risk during the Covid-19 pandemic.

Staff deployment was based on the numbers of people living at the service and not their individual assessed needs. It was unclear how people’s additional care and support needs were being met.

Medicines prescribed to be administered when required, had protocols but lacked specific guidance for staff. Medicine reviews and oversight and management was ineffective due to poor record keeping and follow up.

Staff morale was low, and the staff team did not feel valued and involved in the development of the service.

Systems and processes to assess and monitor quality including health and safety had not been kept up to date.

For more details, please see the full report which is on the CQC website at

Rating at last inspection and update

The last rating for this service was Good (Published 17 January 2019). The rating for the service has changed from Good to Inadequate. This is based on the findings at this inspection.

Before our inspection we received concerns in relation to their being a closed culture, financial and verbal abuse from staff, poor management of incidents and governance. We raised these concerns pre-inspection with the provider but were not sufficiently assured. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

Why we inspected

The inspection was prompted due to co

Inspection areas



Updated 5 August 2020

The service was not safe.

Details are in our safe findings below.



Updated 17 January 2019

The service remained good.



Updated 17 January 2019

The service remained good.



Updated 17 January 2019

The service remained good.



Updated 5 August 2020

The service was not well-led.

Details are in our well-Led findings below.