Woodlands Court Care Home

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 changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 50 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

There was a culture of learning within the service; however, this was not always fully embedded.

Systems were in place to identify learning from incidents. Incidents had been reviewed by the registered manager, and actions had been identified to reduce the risk of them happening again.

However, this learning was not always consistently used to drive improvement across the service. Wider issues identified during the inspection showed that lessons were not always embedded into practice or supported by effective oversight from the provider.

Improvements were required to ensure learning was used proactively to drive sustained improvements in people’s care and safety.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

There were two instances where actions identified by external healthcare professionals had not been followed, for example in relation to people’s care and support needs. This meant people’s needs were not always met in a timely way. In addition, other external professionals had needed to identify that people’s care was not meeting their needs before action was taken, which showed a lack of effective oversight.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Staff had received safeguarding training and were able to explain how to recognise and report concerns. Staff spoken with demonstrated an understanding of their responsibilities and told us they would raise any concerns to help keep people safe.

However, systems to ensure people were protected under the Mental Capacity Act were not always effective. Deprivation of Liberty Safeguards (DoLS) were not always in place where required.

The provider had recently identified that DoLS applications had not been kept up to date and had completed a large number of applications. Despite this, records showed gaps in oversight. For example, one person’s DoLS had expired in July 2025, and an application to renew this had not been completed according to the DoLS tracker.

This meant people were not always legally protected, and systems were not robust in ensuring DoLS were applied for and kept up to date.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People had risk assessments in place which were up to date. These identified risks to people’s health, safety and wellbeing.

However, corresponding care plans did not always reflect the information recorded in risk assessments. This meant staff did not always have clear and consistent guidance on how to support people safely. Staff told us they knew people and their needs well and this knowledge helped to reduce risks.

This lack of alignment between risk assessments and care plans meant that people’s care was not always planned in a way that fully reduced identified risks. Improvements were needed to ensure care plans clearly reflected current risks and set out how people should be supported to remain safe.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The environment was not always safe or well maintained.

Issues had been identified by a fire consultant, all doors in the home required attention to improve safety in the event of a fire. Records showed that 29 out of 56 doors had been addressed; however, a large number remained outstanding, which meant people were not fully protected.

External environmental audits had identified concerns. Although some actions had been taken, such as wall repairs and replacement of a freezer, there was no clear action plan in place to demonstrate how all identified issues would be addressed and completed.

We identified further environmental risks during the inspection in some of the bathrooms and some paving slabs in the courtyard presented a trip hazard.

The main lounge environment was not welcoming or homely. The room was dark despite bright weather outside, and furniture was arranged around the edges of the room in a way which felt institutional rather than comfortable. Seating consisted of individual chairs, and the layout created a walkway for staff rather than a space for people to relax together. Dining tables were not set, and there was no evidence of efforts to create a social or engaging mealtime experience.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

There were enough staff on duty to support people; however, the deployment of staff did not always ensure workloads were manageable.

The nurse was responsible for giving medicines to people receiving either nursing or residential care in the afternoons, evenings and at weekends, as there was no senior carer on duty after 2pm. This was not in line with expected practice and increased the nurse’s workload, reducing time for other clinical tasks.

Nurses also told us they did not always have enough supernumerary time to complete care plans and other records. This meant that documentation was not always kept fully up to date.

The provider was in the process of moving from paper-based training to an online system to support staff learning and development.

Staff supervision had not taken place consistently. The registered manager was aware of this and had identified it as an area requiring improvement.

Staff recruitment processes were safe. Appropriate checks had been carried out before staff started work to ensure they were suitable to support people.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Infection prevention and control practices were not always effective.

We found issues with the availability and suitability of waste bins. In some bathrooms, bins were too small or not working correctly. This increased the risk of infection. For example, we observed a used glove left behind pipework in one bathroom. The registered manager asked staff to address this immediately. However, when we returned later, although the original glove had been removed, another glove had been left on the bathroom floor, which showed a lack of consistent practice.

Clinical waste bins were stored inside cupboards. This meant staff needed to open cupboard doors by hand before using the foot-operated bin, which increased the risk of cross-contamination.

However, we observed that nursing staff followed good infection prevention and control practices when supporting people. This included the appropriate use of personal protective equipment (PPE) and following good hygiene procedures.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Family members told us their loved ones received their medicines as prescribed, and they were kept up to date of any changes. A relative said, “I’m told if there are any changes to her tablets.” Another relative told us, “No problems with tablets, we haven’t needed a GP since coming here.”

However, we found a person had not received their prescribed medicine for 16 days because it was not available in the service. The management team acknowledged this was an oversight and that action should have been taken more promptly. This placed the person at risk of harm. Additionally, best practice had also not been followed, as individual fire risk assessments had not been completed for people using paraffin-based skin products.

We also observed that the nurse administering medicines was frequently interrupted during the medicines round. This increased the risk of error and meant safe administration practices were not always followed.