The Woodlands 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 inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of the legal regulations relating to safe care and treatment, safe environments and safe management of medicines.

This service scored 25 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The provider had not been effective in identifying areas of improvement within the home environment to reduce the risk of people injuring themselves. People were exposed to the risk of harm because risks to their health and safety had not been adequately assessed, and not all that was reasonably practicable had been done to mitigate such risks. We observed a window restrictor within a person’s bedroom on the first floor was damaged and not fit for purpose, this had not been identified within health and safety audits. The Local Authority identified this as an area of improvement at the last visit to the service.

Risk assessments failed to identify environmental hazards to people and if adaptions to the environment were required to support people mobilising safely around the service.

Incident analysis following accidents and incidents was not robust. We could not be certain trends where being identified and appropriate actions taken to prevent further accidents and incidents re-occurring.

Whilst the provider carried out an annual satisfaction survey with people, this had not been effective in identifying some people's concerns about the care and support they received and lack of activities.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The provider had not been effective in identifying areas of improvement within the home environment to reduce the risk of people injuring themselves. People were exposed to the risk of harm because risks to their health and safety had not been adequately assessed, and not all that was reasonably practicable had been done to mitigate such risks. We observed a window restrictor within a person’s bedroom on the first floor was damaged and not fit for purpose, this had not been identified within health and safety audits. The Local Authority identified this as an area of improvement at the last visit to the service.

Risk assessments failed to identify environmental hazards to people and if adaptions to the environment were required to support people mobilising safely around the service.

Incident analysis following accidents and incidents was not robust. We could not be certain trends where being identified and appropriate actions taken to prevent further accidents and incidents re-occurring.

Whilst the provider carried out an annual satisfaction survey with people, this had not been effective in identifying some people's concerns about the care and support they received and lack of activities.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not 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 share concerns with relevant stakeholders quickly and appropriately.

We observed staff living within a flat on the second floor of the building in poor conditions and within an unsafe environment that posed a risk to people. The area was cluttered with combustible items and unsafe storage. Access to the area was not secure and the conditions within to the flat were unsafe. The provider had failed to ensure risks identified were managed and mitigated to prevent incidents or a risk of fire. Concerns relating to fire safety were reported to Merseyside Fire and Rescue during the assessment. The impact of the staff living area posed a risk to people living within the service therefore safeguarding concerns were reported to the Local Authority following the assessment.

Staff had completed safeguarding training and told us they understood their responsibilities to keep people safe, however, some staff raised concerns management did not thoroughly investigate concerns reported from people. Records did not reflect the concerns shared with us or evidenced what actions were taken, this evidenced the providers safeguarding policies and procedures had not been followed.

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

Care plans and risk assessments were not sufficiently detailed, lacked person-centred information, and did not provide staff with clear guidance on how to manage and mitigate identified risks. Falls and accidents and incidents had not been regularly reviewed or analysed to inform learning or establish preventative action.

Between December 2024 and May 2025, a person had experienced a high number of falls. There was a lack of assessment of the falls and actions to prevent reoccurrence. The environment had not been assessed to identify any risks or adaptions required to support the person with mobilising.

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

The flat on the second floor of the building presented as a fire and health and safety risk. Items belonging to the care home were stored unsafely within an area of the flat including equipment, radiators, paints, building materials and activity items.

Parts of the service were not in a good state of repair. The décor to some areas of the home required improvement. There were a number of hazards identified, for example, nails/hooks in walls at head height and within shower rooms and a damaged window restrictor to a person’s bedroom. Some areas of the home were missing grab/handrails. The provider had installed new radiator covers to most of the radiators however, some were missing. High risk areas such as the laundry and electrical cupboards were unlocked and accessible to all.

The laundry contained black mould on the walls and rising damp. People’s clean clothes were stored next to areas of mould. There was limited ventilation in the room and dirty mop heads stored in the sink.

The manager told us they completed regular walks around the service and audits were available. The audits failed to identify any of the concerns found during the assessment.

The provider did not 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 work together well to provide safe care that met people’s individual needs.

People raised concerns about staffing levels, one person said, “I’m bored all the time, there are no activities and the staff are so busy.” Relatives echoed these comments and one person said, “They are so busy all the time. There is no entertainment and the minibus has been broken for a year.”

Staff worked multiple roles within the service, this impacted on people’s access to support with daily care needs, access to activities and social isolation. For example, a staff member was declared on the rota as cook and activities. The staff member advised they switched roles in the afternoon and then swapped back late afternoon; this did not happen during both visits to the service due to the demands of working in the kitchen as the cook.

A dependency tool was used to identify the needs of people and calculate the number of staff needed to provide people’s care. The dependency tool was not a true reflection of people’s dependency. The hours calculated within the tool were not an accurate representation of the support needs for people. This was discussed with the manager who advised due to funding rates there was no flexibility with staffing.

Documentation was in place to satisfy safer recruitment; however, gaps were identified with regards to references and gaps in previous employment history. Newly recruited staff files were not as robust, for example, a reference for a staff member was not sought from the most recent employer.

The use of split roles was ineffective as observed on the first day of the assessment. Staff did not have the time to provide activities. People who required supervision when mobilising, particularly those within bedrooms were not in receipt of this and a high number of falls were unwitnessed within bedrooms and communal areas.

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

The provider had not been effective in identifying areas of improvement within the home environment to reduce the risk to people. Parts of the service were not clean and tidy. Cleaning audits for the day before and during the assessment reflected deep cleans of areas within the service, this was not evident. Areas were visibly dirty with cobwebs and dust within peoples’ bedroom’s; toilets were visibly dirty and they had not been cleaned for some time. We identified multiple razors within a person’s bathroom on the floor and behind the sink. This put people at risk of cross infection.

The flat on the second floor was dirty and unkempt with out-of-date food, drinks, and other items observed. The area was cramped with various items and was unable to be cleaned effectively. The manager acted on the first day of the assessment and cleared the room to enable it to be cleaned.

The provider did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Medication storage was not safe. Large amounts of medication including creams belonging to people were found in bags within the second-floor flat being occupied by staff. Systems to manage the safe storage of medications and disposal were not in place.

The medication stock return book had not completed for some time and the last medications to be returned to the pharmacist were dated July 2024. The stock count book made no reference to the medicines found within the second floor flat. Returns or disposed of medications were not recorded or stored within the correct storage facility as indicated within the providers medication policy. There was a lack of systems for reporting errors with no evidence of error/incident forms being completed for future learning, risk mitigation or analysis of themes. Staff confirmed there were no systems in place to record errors.

Handwritten medication administration records (MAR) were in place, there were however not, signed by two staff to ensure accuracy.

Pharmacy warnings were not recorded on MARS. We observed staff administering medication to a person who should have been given the medicine with food. We saw staff administer the medication 1.5 hours before food was provided.

Protocols were in place for medicines prescribed ‘as required’ basis, often known as PRN. However, the records did not record the reason for administration, effectiveness or protocol for variable doses.

There were gaps identified for temperatures of the storage facilities where medicines were kept.