Woodlands Care Centre

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.

The service was in breach of legal regulations in relation to safe care and treatment and safe staffing.

This service scored 44 (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. Processes for reviewing and analysing incidents, accidents, safeguarding concerns and complaints were not sufficiently robust. There was no effective system to identify patterns and trends, evaluate the effectiveness of actions taken, share learning, or monitor whether improvements were sustained. Where learning was identified, it was often shared only with nursing staff with limited evidence that care staff responsible for delivering day-to-day care and support were included. This reduced opportunities for all staff involved in people's care to reflect on incidents, embed learning and improve practice. Staff told us that debriefs following incidents were not consistently undertaken, resulting in missed opportunities to learn from events and drive continuous improvement in practice.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always make sure there was continuity of care, including when people moved between different services. People were supported to access hospital treatment when required, and staff sought medical assistance appropriately. However, the quality of records was inconsistent, which meant continuity of care could not always be assured. Some care plans and risk assessments lacked sufficient detail. This increased the risk that people may not receive care that reflected their current needs, including during hospital admissions or transfers between services.

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. Although staff had completed safeguarding training, not all were able to confidently explain safeguarding procedures or their responsibilities. Discussions with care staff indicated a reliance on reporting concerns to nursing staff, with limited understanding of wider safeguarding processes, including when concerns should be escalated externally. During the inspection, we identified an occasion where a safeguarding concern had not been promptly referred to the local authority safeguarding team. This demonstrated a failure to recognise and escalate a potential allegation of abuse or neglect, without delay.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this is achieved through the Deprivation of Liberty Safeguards (DoLS), which form part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how DoLS were managed. We found leaders and staff had appropriately sought DoLS authorisations where required. Decisions were made in people’s best interests, were proportionate to the risks identified and helped to keep people safe.

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. Whilst no evidence of actual harm was identified, we found that systems and processes were not always effective in ensuring risks to people’s health, safety and welfare were appropriately managed. Care plans and risk assessments were not always accurate, complete or reflective of people’s current needs. We identified omissions, contradictory information and missing information. This meant risks in relation to falls, epilepsy, diabetes, nutrition and hydration and skin integrity were not sufficiently assessed, and risk management plans did not provide adequate guidance to support people safely. Staff did not consistently follow risk assessments or complete required monitoring. We observed examples of unsafe practice, including inappropriate moving and handling and food being provided contrary to a person's assessed dietary needs. This placed people at risk of avoidable harm.

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. We identified environmental safety concerns during the inspection, including an external fire door that did not close properly. The provider took immediate action to address this during our site visit. We also found cleaning products stored in unlocked cupboards within kitchenette areas, meaning people could potentially access hazardous substances. The environment was not always maintained to a standard that supported safe care. Several areas of the home showed signs of significant wear and tear and required refurbishment. The provider had recognised these concerns and had already commenced a programme of environmental improvements. However, several issues remained unresolved at the time of inspection. This meant people were not always cared for in an environment that was safe, well-maintained and fit for purpose.

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. Staff told us they did not routinely receive regular supervision, appraisals or team meetings. They told us they did not feel supported by management and lacked opportunities to discuss performance or concerns. Several described a culture where poor practice was not consistently challenged and where they did not feel valued or listened to.

Concerns about staffing levels were raised consistently by people, relatives and staff. People told us they experienced delays in receiving care and support. One person told us, “It’s terrible. If I press the buzzer they don’t come. I have to wait to go to the toilet and then I have an accident... I ring the buzzer at 9am and they say they will be there in 10 minutes and that stretches to an hour.” Another person told us they often remained in bed until 11am and were not offered breakfast until this time. Care records confirmed this. Relatives also expressed concerns. One relative told us, “Today there was only one carer with the residents in the lounge. A lady wanted a drink, and no one came to her. My daughter had to give her a drink…when I look for staff, there’s no one to ask.”

Staff told us staffing levels did not always reflect the dependency and complexity of people’s needs. One staff member said, “On my unit a lot of people require 2:1 for personal care and this may take 30 minutes each. It is hard to do this well and give quality care when you have so many people to support and not enough staff.” Another told us, “On paper it might seem like the staffing levels are enough but a lot of the people we support are vulnerable and can become agitated.” Although the provider used a dependency tool to determine staffing levels, the Home Manager acknowledged that people's dependency needs had not always been calculated accurately in the past. They also recognised that high agency staff usage, combined with a historical lack of staff support, oversight and guidance, had contributed to staffing pressures and inconsistencies in care delivery. At the time of the inspection, the provider had started to address these issues through increased recruitment, higher staffing levels and the introduction of regular agency staff, familiar with the service. However, these measures had only recently been implemented and it was too soon to assess their impact or effectiveness.

The provider did not consistently assess, prevent, detect or control the risk of infection. Systems were not effective in identifying and addressing environmental concerns, food hygiene risks and infection prevention and control (IPC) issues in a timely manner. As a result, people were exposed to avoidable risks that could increase the likelihood of infection and compromise their safety and wellbeing. People, relatives and staff raised concerns about IPC practices. Relatives told us staff usually wore gloves but did not always wear aprons, and some staff reported shortages of aprons on certain units. One relative told us, “Well it’s not bad [cleanliness]. Not brilliant. It smells in [relative’s] room. The chair cushion has a mess on it. Staff don’t clean this; they just turn it over. I’ve asked them twice to clean it, and I’ve cleaned it myself before.”

The provider did not ensure the environment was maintained in a way that supported effective infection prevention and control. We observed damaged worktops on 1 unit which could not be effectively cleaned or disinfected, increasing the risk of contamination. A persistent odour of urine was also evident within communal areas on 2 units, which relatives told us had been present for several months. Although the provider had arranged deep cleaning, this had not resolved the issue. While replacement flooring had been planned, this had not been installed at the time of inspection. These findings demonstrated that environmental hygiene risks were not being addressed promptly or effectively.

Food hygiene risks were not consistently managed within the kitchenettes on individual units. We found food stored without labels or opening dates, unwrapped food in refrigerators, and food left out overnight, increasing the risk of contamination. Standards of cleanliness were also poor, with dirty surfaces and appliances observed across units. Although the provider was aware of an ant infestation and had sought advice from pest control, we observed ants in kitchenette and dining areas, where food debris and crumbs were present. These conditions were likely to contribute to the persistence of pests and undermined efforts to maintain a clean and hygienic environment.

The provider managed medicines safely and in line with people’s needs. Medicines were stored appropriately, including temperature-controlled items, and administered using an electronic system. Allergies, diagnoses and administration requirements were clearly recorded, and time-critical medicines were given as prescribed. People receiving medicines via PEG tubes and those receiving medicines covertly had appropriate assessments and records in place. Controlled drugs, analgesic patches and PRN (as required medicines) medicines were managed safely, and staff followed appropriate processes to support people before administering medicines prescribed for agitation. We observed 1 member of staff not following policy when administering an oral liquid medicine and found daily checks of an analgesic patch had not been documented. The provider addressed these issues immediately. Medicines-related care plans were in place, and staff had completed training and competency assessments. However, some care plans lacked detail or had not been updated to reflect current needs, including guidance for PRN pain relief and end-of-life medicines. Regular audits were completed by the provider and supplying pharmacy, and no medicines incidents had been reported in the previous 6 months.