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 inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm. The provider was in breach of the legal regulation in relation to safe care and treatment.

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. Lessons were not learnt to continually identify and embed good practice. Although the provider kept a learning log and safeguarding records, these did not show learning was being used effectively to improve care or reduce risks. The learning log mainly recorded actions taken after incidents rather than how future risks would be prevented. Not all significant incidents were included, including serious falls, and where learning was recorded, it was not clear how this had been put into practice. There was no evidence of effective oversight to check whether actions taken after incidents had worked. Records did not show how actions were monitored, whether risks had reduced, or how the impact of changes was reviewed.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services. People at risk of falls were not always given the support or supervision they needed. Some people experienced repeated falls, including unwitnessed falls that resulted in injury. Although actions such as increased supervision and monitoring were recommended after incidents, there was little evidence these changes were consistently put into practice. Known risks and agreed control measures were not routinely followed in day-to-day care, and there was insufficient evidence care plans or risk assessments were updated following incidents.

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. Safeguarding records showed several incidents that resulted in harm, including unwitnessed falls and injuries. However, the provider did not always make safeguarding referrals at the time incidents occurred. The provider also did not refer some concerns to the Local Authority or notify CQC promptly, despite these concerns involving significant risk, including unwitnessed falls and deterioration in people’s mental health. Records for one person showed repeated falls over time, including falls resulting in fractures, had not been appropriately recognised or reported as safeguarding concerns. A safeguarding referral was only made after intervention by the Local Authority. Records were incomplete or unclear, incident dates did not always match information held by external agencies, and safeguarding logs were not consistently dated or accurately maintained. Staff demonstrated awareness of safeguarding processes and reporting procedures. Comments included, “I am aware of policies like safeguarding, incident reporting, whistleblowing and infection control,” “I know how to report concerns, and I can access policies when needed,” and “I am aware of the procedures for reporting incidents.”

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. People were not consistently supported with clear information to make informed decisions about managing risks. Care records did not always provide a clear or shared understanding of people’s risks and support needs. When incidents occurred or people experienced changes in their health or behaviour, there was limited evidence their views had been sought, or care plans and risk assessments had been updated accordingly. Risk management was not always described in a person-centred way, which limited staff’s ability to support people safely while also promoting choice, dignity and independence.

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. Parts of the home were not well maintained and were in a poor state of repair. The environment was not consistently safe or adequately maintained. Some decorative improvements were made subsequent to our visits.We identified environmental hazards throughout the home, including a broken radiator with a loose exposed wire, flooring lifting creating trip hazards, broken furniture and drawers, peeling and crumbling skirting boards, plug sockets coming away from walls, and exposed cable trunking and beading with visible nails. The provider did not address these risks through regular checks or maintenance arrangements. Hazardous areas and substances were not always managed securely. We found the sluice room and larder were accessible, the COSHH cupboard lock was broken (and subsequently repaired), and hazardous cleaning products were accessible. We found the Registered Manager’s office was unlocked and contained full urine sample bottles, power tools and hazardous substances. One person’s bedroom was found dirty and unsafe despite care plans stating staff should support the person to maintain a clean and safe environment. Environmental features did not always support safe use. The garden area was unkempt, lacked safe seating, and the summer house was being used for storage rather than activities, limiting safe access to outdoor space. Feedback from relatives was mixed. Some relatives told us, “It’s safe,” and “Yes, it is absolutely safe,” while others identified concerns about delays in addressing environmental risks. One relative said, “I had to mention it a couple of times. They eventually sorted it,” and another reported, “I did complain but it was only sorted 3 months later.”

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. Staff did not have sufficient time to provide meaningful activities, and people who required supervision were not always supported safely. Staff rotas, when reviewed alongside people’s needs and incident records, showed staff were frequently required to carry out multiple roles, including care, cooking and cleaning. A dependency tool is used to assess peoples’ needs and determine how many staff are required to meet these needs. The dependency tool was not based on individual need and used repetitive time allocations, including a standard ten minutes for activities. There was no clear evidence to demonstrate staffing levels were appropriate. Records showed limited evidence of structured induction, supervision or appraisal, and insufficient oversight of staff competencies. During our observations, at times, only one care staff member appeared available, reducing effective supervision. Relatives described staff as “friendly and helpful” but also said, “Staff could do with more support from management. They work really hard.” Although staff spoke positively about training, this was not reflected in practice, where staffing and deployment impacted on safe care delivery.

Staffing levels and deployment did not always support safe supervision. We observed people were left unsupervised in communal areas, including people at risk of falls and people with visual impairment. Where care plans identified that people required support with personal care, continence, nutrition, mobility and maintaining a safe environment, this support was not consistently provided in practice. We observed periods where no staff were present in certain areas of the home, despite people being at risk. For example, one person attempted to mobilise independently without staff support, and there was no staff presence for several minutes.

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. We found widespread concerns with cleanliness and infection prevention and control throughout the home. Communal bathrooms were heavily soiled, with faeces and urine found on equipment, and soiled underwear present. Communal areas were not maintained to an acceptable standard of cleanliness. Pressure cushions were visibly dirty, furniture was stained and contained food debris, unpleasant odours were evidence, and some surfaces could not be effectively cleaned.

People’s bedrooms and personal spaces were also not consistently clean. [MH1]Cleaning responsibilities set out in care plans were not consistently followed. Audit records indicated standards were being met, but this did not reflect the conditions we observed.

[MH1]I think this has been repeated from above

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. Systems for the safe storage, administration, recording and monitoring of medicines were not effective. We found medication keys in a basket on top of the medicine cabinet, and the office housing the medicines cabinet was left unlocked on several occasions, meaning medicines were accessible to unauthorised people. Records for medicines given on an as-required basis did not always record the time of administration. Eye drops were found without opening dates recorded, and staff were observed handling medicines with bare hands during a medication round. Arrangements for medicines requiring refrigeration were not found to be initially safe. The medicines fridge did not have a minimum and maximum thermometer, there was no maintenance log, and temperature records did not show acceptable ranges or required actions if temperatures fell outside safe limits. An appropriate thermometer was purchased subsequent to our assessment. Care records contained conflicting information about how medicines should be managed for some people, and medication when needed (known as PRN) was unclear and not safely implemented. The provider’s Medication Root Cause Analysis Report described medicines governance as robust and effective, but this did not reflect the concerns we identified.