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 requires improvement. At this assessment the rating has remained 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 regulation in relation to safe care and treatment including the way people’s medicines were managed safely and safe management of risks related to people and environmental risk.

This service scored 62 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There was a positive learning culture in the care home where managers and staff understood the importance of reporting safety concerns and learning lessons when things went wrong.

Managers investigated safety concerns and events and used the learning from these to support staff to continually improve their practice, reduce risk and keep people safe. For example, incidents and accidents had been recorded and reviewed by the management team. Any lessons learned were identified and shared with staff during handovers, meetings and the providers secure messaging system. The provider submitted appropriate notifications to CQC and the local authority.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

In circumstances where a person moved between healthcare provisions, for example to hospital, information via a hospital passport was shared promptly. This ensured the person received continuous care and support.

There was an admissions process and policy in place. This meant pre-admission assessments were completed before people moved into Woodlands care home and staff had information about how to meet people’s needs. Staff made referrals and worked with other agencies to make sure different aspects of people’s health and wellbeing were considered by the appropriate health professionals.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Systems were in place to record any safeguarding concerns. Staff were able to describe signs of potential abuse and were confident these would be dealt with appropriately by the management team. Staff had received training in safeguarding.

People told us that they felt safe living at the service. Feedback from people and relatives included, “I love it here, the staff are very good and look after me well”, “Definitely feel [family member] is safe here with staff and if I didn’t [family member] wouldn’t be here” and “I feel [family member] is safe around staff and have total peace of mind, we get introduced to new staff”.

The service had made appropriate Deprivation of Liberty Safeguards (DoLS) applications for people who required them.

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.

Where people had specific health needs which placed them at risk of harm, such as epilepsy, risk assessments had not always been completed and the risks relating to the condition had not been fully considered. For example, one person had a diagnosis of epilepsy and whilst this was well controlled with medication, there was no care plan or risk assessment in place for this condition to provide staff with information, guidance or advice on how to monitor, support and escalate concerns should the person become unwell or experience a seizure.

We were not assured people at risk of developing pressure injuries had been repositioned in-line with their assessed need. For example, one person’s care plan stated, they needed repositioning every 3 hours. We reviewed this person’s repositioning records for a 7 day period from 30 September to 6 October 2025 and identified they had not always been repositioned as described. Out of 34 repositioning entries, there were 27 occasions repositioning had taken place between 3.5 hours and over 5 hours. People were placed at risk of experiencing skin damage.

Risks to people were not always effectively monitored. Some people were placed at risk of constipation due to the lack of guidance in care plans. For example, a person was described as suffering with chronic constipation, however, there was no risk assessment and a lack of guidance for staff about the management of constipation. This included a lack of detailed information in relation to what ‘when required’ medicines had been prescribed, when to give these and frequency, and what a normal bowel pattern was for the person. This meant signs of constipation signs could be missed, delaying prescribed medication being administered.

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 found shortfalls in the safe management of risks related to the care home environment. There was an absence of appropriate measures to ensure people, staff and visitors accessing the building were appropriately protected from environmental risk.

The provider had ineffective systems to ensure water safety at the service. There was not a robust system in place or management oversight to ensure that these were being completed correctly. For example, the monitoring checks did not record the actual temperatures of the hot and cold water being dispensed from all water outlets. This gave no assurances that water temperatures were within the safe ranges as they were not documented. This placed people at risk of scalds and Legionnaires' disease, a serious form of pneumonia. Whilst the provider told us that they would revise the recording records, this change had not been embedded into practice.

Staff and leaders were not always clear of their responsibilities in relation to compliance with health and safety requirements. For example, maintenance staff delegated the task of assessing the window restrictors was not able to tell us what the requirements were. This placed people at potential increased risk of harm due to lack of staff knowledge.

On day 1 of our visit on 6 October 2025, we observed that the provider had failed to ensure window restrictors were in place on some of the windows that required them within the home, such as, bedrooms, bathrooms and communal areas at ground floor and 1st floor level, this was raised with the management and maintenance team. However, during day 3 of our visit on 24 October 2025, window restrictors had still not been placed on all windows that required them. This placed people at potential risk of harm.

The processes in place for the monitoring of call bells was not effective or robust and it did not identify the shortfalls we found on this inspection. For example, we observed call bells were not in place in areas where they would be required to ensure people could summon help, especially where people were mobile. We observed ensuite areas in some people's bedrooms had no call bells in place. This meant they were not able to seek staff assistance in these ensuite areas.

Fire door checks had been completed monthly throughout the year of 2024, however there were no records for 2025. Staff told us that the fire door checks were now incorporated into the weekly fire alarm test, however these checks were ineffective and did not identify the issues we raised on this inspection such as excessive gaps on a laundry door, boiler room cupboard and bedroom door. Fire doors are designed to resist the spread of fire for a period of time, normally a minimum of 30 minutes. Excessive gaps in fire doors can compromise the containment of fire and smoke which placed people at risk of harm in the event of a fire.

Regular servicing checks of the building had been completed, this included gas safety, electrical installation and fire systems. Certificates of any works completed were readily available.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care which met people’s individual needs.

There was good deployment of staff throughout the service and we observed people being supported by members of staff who were kind and caring. People, relatives and staff all said there were enough staff and one person told us, “Yes there is [enough staff]. A relative told us, [Family member] has a lot of time for all the staff and it seems like a family". A staff member told us, "Goes with the business of the day, more often or not can feel that may need more [staff] however management will step in and work on the floor”.

Staff described their induction and said the management checked their confidence and competency through regular training and supervisions.

One staff member told us the training they receive was, "Effective, equips me to respond to peoples care needs in the moment”.

Another staff member told us they had been supported with further training opportunities to develop their skills and knowledge and help them progress in the role.

Recruitment processes were effective and staff were employed safely and appropriate pre-employment checks were completed for each member of staff.

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.

People were protected from the risks associated with the spread of infection because staff followed the provider’s procedures and best practice. All areas of the home were clean and smelt fresh. Good stocks of cleaning products were evident. Cleaning schedules were completed to ensure good hygiene standards were maintained. Designated cleaning staff were employed.

Staff were observed using personal protective equipment (PPE) such as gloves and aprons, appropriately. Staff had access to the personal protective equipment (PPE) they needed when supporting people with personal care. Handwashing facilities and sanitising gel were appropriately sited throughout the home.

An infection, prevention and control policy was in place which was regularly reviewed to ensure it reflected current guidance and best practice. Staff had received training in infection, prevention and control.

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

The provider failed to operate an effective system to ensure that food and fluid thickening power was safely stored. For example, on day 1 of our visit we found 1 tub of thickening agent in the dining area and accessible to people. We informed the management team immediately on their arrival to the service. However, on day 2 we found a further tub of thickening powder on top of an unattended medicine trolley in a corridor which was easily accessible to people. This was again immediately raised to the management team. This meant people could access the thickening agents inappropriately which placed them at risk of harm.

A person who was prescribed the use of a transdermal patch, had no accurate body map in place. Application records on the electronic medicine administration record (eMAR) did not accurately record where patches had been applied and the service did not have an alternative method of recording in place. Staff told us that they rotated the patch between 4 sites on the person’s body. However, the manufacturers guidance is to avoid using the same application site for 14 days. The lack of rotation could lead to an increase in adverse reactions or potential overdose of a medicine.

We found some topical creams did not have the date of opening or expiry dates recorded and some had illegible labels. This included creams that needed to be discarded after 3 months. For example, we found a topical cream that was in a person’s room that did not have an opening date. The dispensing date was November 2021. This meant topical preparations could continue to be used even when it was no longer safe.

Controlled drugs were not well managed. Controlled medicines (CDs) are medicines which are subject to strict legal guidelines around their use. However, from review of the controlled drugs register we identified that the register was not fully completed upon receipt of controlled medicines, doses were not always fully recorded, the person administering the controlled drug was unclear and on one occasion this was not recorded. This meant records were not kept in line with regulations.

Some people were prescribed 'as needed' (PRN) medicines, which require clear protocols for their use. Guidance in the form of protocols or care plans were not always in place and the ones we reviewed were not person centred or individualised. This meant the provider could not be assured PRN medicines were always administered consistently. These included medicines prescribed for people’s allergies, constipation and anxiety. This information is useful in monitoring a person and deciding if they needed reviewing by the doctor.