Woodside Lodge

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

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

The provider was previously in breach of the regulations in relation to safe care and treatment, safeguarding, staffing and fit and proper persons employed. Improvements were found at this assessment, and the provider was no longer in breach of these regulations.

This service scored 69 (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 listened to concerns about safety and investigated and reported safety events. We saw examples of lessons being learned in response to incidents. Staff meeting minutes showed areas for learning and improvement were discussed at staff meetings. Accidents and incidents were analysed to identify themes and trends.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care. For example, we saw information was shared with professionals to support referrals to different health services when needed, in line with their individual needs.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Safeguarding concerns were identified, reported to the local safeguarding authority and investigated. The provider reported safeguarding concerns to relevant organisations.

People we spoke with told us they felt safe, and we observed kind interactions between people and staff. When people were deprived of their liberty, the provider made Deprivation of Liberty Safeguards (DoLS) applications.

Staff received safeguarding training and the provider had a safeguarding policy detailing how to respond to safeguarding concerns. We saw evidence of safeguarding concerns being reported to the local safeguarding authority and CQC when required.

The provider worked with people to understand and manage risks. Staff provided care to meet people’s needs that was safe and supportive.

Risks to people were assessed and actions taken to reduce the risk of harm. For example, risk assessments and support plans were completed in relation to risk of skin breakdown, malnutrition and falls. Records showed these were regularly reviewed and updated. We observed staff supporting people in line with their risk assessments and support plans.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Records showed environmental checks were completed, and action plans were developed in response to risk assessments to reduce identified risks. For example, in relation to fire safety and legionella. The provider had systems and processes to monitor the safety and upkeep of the environment.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Staff were recruited safely and received effective support and supervision.

We could not be assured staffing levels were always sufficient to meet people’s needs. The provider told us a minimum of 4 care staff were required on shift during the day. However, rotas showed times where staffing levels fell below 4. We observed some occasions where staff were not available in communal areas to support people who were assessed as requiring staff supervision. For example, due to risk of falls. The provider’s falls analysis for January 2026 identified a higher number of falls between 2pm and 8pm. It noted an action to continue to monitor and assess staffing dependency, as no staff shortages were noted. However, we did not see any increase in staffing levels since this time. In the provider’s September 2025 staff survey, multiple staff commented they felt more staff were needed. Feedback from people and relatives about staffing levels were mixed, some felt there were enough staff and others felt more were needed.

Recruitment files contained information required by the legislation. Staff received training and regular competency checks in areas relevant to their roles.

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. A relative told us, “It is always kept clean”. Cleaning schedules were completed, and the home appeared generally clean without malodour. We saw evidence of regular audits, and prompt action was taken to address identified shortfalls.

The provider did not always make sure medicines were consistently managed safely.

When people were prescribed ‘when required’ (PRN) medicines, protocols sometimes lacked detail. For example, when to offer the medicine or when to escalate for review. Protocols for some PRN medicines were not completed, for example for medicines prescribed for pain relief or to relieve constipation. The provider was aware of the shortfalls and was working to improve these. The medicines room and fridge temperatures were not always robustly recorded or escalated when there were gaps in recording, or the temperature was noted as out of range. We raised this with the provider who addressed this immediately.

The provider had policies and procedures to order, record, store and dispose of medicines safely. These followed current legislation and relevant best practice guidance. Staff recorded the date of opening and expiry date on liquid medicines and creams. When staff administered insulin as a delegated task, they received training and had their competency assessed by a registered nurse as required to administer safely.