Woodways

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice. Accidents and incidents were effectively recorded and monitored, to learn lessons and mitigate risks posed to people. Accidents were monitored through a health and safety committee, and the management team reviewed accidents and incidents, including any actions which were required. Monitoring was in place, to enable people to receive the least restrictive support possible. For example, 1 person recently had some environmental safety restrictions removed. This had enabled them to maintain their independence, where they had previously been restricted. The provider had a proactive approach to risk management, which balanced risk and opportunity. Incidents were discussed in team meetings and daily handovers. Where people had incidents of distress, the provider had produced example incident forms, for staff to follow as guidance, to ensure staff understood the level of detail required in these records. Staff were involved in debriefing sessions following behavioural incidents, to reflect upon what went well, what could be done better and if any changes were needed to the staff’s approach.

The provider always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services. Staff worked well with partners and external professionals to ensure people had their needs met and a continuity of care was maintained. Some people had been supported to move to the service from previous more secure services. Staff had worked closely with external professionals, which had enabled people to live at Woodways in the community. This had improved their quality of life, and maximized their choice, control and independence. For example, 1 person was supported to attend the theatre for the first time, and another person was supported to obtain a pet. People had detailed pre assessments in place, to ensure people's needs and wishes could be met, this included an assessment to ensure people would be suitable living together.

The provider worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. Staff had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider always shared concerns quickly and appropriately. Staff understood their responsibilities to report concerns, and all staff told us the management team was approachable and listened to them. A staff member said, “I have never had to report any concerns, people are 100% safe here. The managers are super; they are so good at listening. Supportive in every way.” Staff were trained and safeguarding was discussed in team meetings. Staff could also use confidential drop boxes to raise concerns if required. Without exception people told us they felt safe and happy living at the service. A relative said, “The service is really good. [Name] gets the care they need. No issues at all with them. [Name] is in a happy, safe place.” Staff had supported a person to report some historical concerns to the police and notifiable incidents were reported to external agencies.

The provider always worked well with people to fully understand and manage risks by thinking holistically. Staff provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them. Risks posed to people were assessed and mitigated. Risk assessments were person centred and care plans contained detail about how to support people to live safely, whilst also taking positive risks. Where people displayed behaviours of distress, a dedicated positive behaviour support team was in place, who closely monitored incidents, trained and mentored staff. A functional behavioural analysis and positive behaviour support plan was in place for each person, these were extremely detailed, giving staff step by step guidance and strategies, to ensure people not only had a great quality of life but also enabled staff to identify when they need to intervene to prevent or reduce the likelihood of an incident. The service was part of a restraint reduction programme, and staff used the least restrictive interventions to keep people safe. People living at the service had had reductions in behavioural incidents, which had positively impacted their lives. A person said, “It's amazing the support I get with my behaviours. Staff encourage me to eat well and cook as I have a history of anorexia. I get 2:1 support and I am happy with this. They give me my own space, and I need it. They understand my needs and are respectful. I feel safe and I have got my own key. I am glad I came here. I am very content. I have everything I need.”

The provider was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care. The service had their own dedicated maintenance staff, who were trained in a range of maintenance subjects, such as fire safety, legionella management and health and safety. Checks were in place for the environment and equipment. Health and Safety meetings took place regularly, to monitor the safety and maintenance of the building. People and staff were involved in fire safety drills, including night-time evacuations, and people had detailed personal evacuation plans in place. Innovative ways were explored to assist people to undertake fire safety evacuations, such as using visual fire boards, to assist people to understand and respond. People's living spaces were tailored, to ensure people were kept safe and promote their independence. For example, where required people had safety walls and windowsills, integrated mirrors, push button taps and lockable cabinets for items which could pose a risk to them. This was risk assessed for each person, to ensure people lived in the least restrictive environment, whilst keeping them safe. people felt safer and more confident in their own homes, with reduced anxiety and fewer incidents of distress.

The provider made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. They worked together well to provide safe care that met people’s individual needs. People were supported by their own staff on a 1:1 or 2:1 basis each day, this enabled people to choose what they liked to do each day. Staff were recruited safely, and new staff received an induction, shadowing opportunities and an allocated mentor. Staff were trained in a high number of subjects to enable them to effectively support people. This included learning disabilities, autism, anxiety, personality disorders, life support, communication, and positive behaviour support. A staff member said, “It is very well and good here, from the management team, staff to the people, everyone is good, everyone supports each other. Managers are good, they listen to us and support us.” People and relatives told us staff treat them very well. A relative said, “The staff are friendly and polite. Nothing needs changing. [Name] is happy and settled. If I could score them out of 10 it would be a 20 from me.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff were trained in relation to infection, prevention and control and we observed staff wearing Personal Protective Equipment appropriately. Systems were in place to promote safe Infection, Prevention and Control (IPC) practices, such as cleaning schedules and auditing. People had their own apartments, which included a bathroom, kitchen and laundry facilities. Staff supported people to complete their own laundry and washing up. The service had a score of 99% from an external IPC audit.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. People’s medicines were stored safely and securely. Temperature records to ensure the safe storage of medicines were not completed in accordance with national guidance. This meant we could not be assured that medicines requiring refrigeration were safe for use. However, management implemented new processes to address this issue whilst we were onsite. The service had individual flammable risk assessments in place for people who were prescribed paraffin-based skin products. Detailed guidance specific to each person on how to administer medicines prescribed as and when people required them, known as “PRN” was available to staff. Instructions for medicines which should be given at specific times were available. Administering medicines as directed by the prescriber reduces the risk of the service user experiencing adverse effects from the medicine. We checked the quantities and stocks of medicines and found stock balances to be correct. This meant that we could be assured that the correct doses of medicines had been administered as signed for by staff. The use of topical creams and ointments were recorded on the medicines administration records (MARs). Body maps were in place to show staff the site of application. There were no controlled drugs on site at the time of our inspection. However, there were appropriate arrangements in place to enable the safe management of these if need be. Records were completed to indicate the name and quantity of medicines taken on offsite visits. There was a process in place to record medicines related incidents or errors. Some people had a different routine, and this was accommodated to ensure they were kept safe. Records showed that staff had received medicines handling training. Staff competencies were assessed regularly to make sure they had the necessary skills. Managers and members of staff qualified to handle medicines regularly completed audits (checks) to make sure that procedures were followed.