Woodside Nursing 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 inspection we rated this key question good. At this assessment the rating has remained good.

This meant people were safe and protected from avoidable harm.

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 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. People told us they were able to raise concerns with staff and management and were confident their concerns would be acted on. Where people had raised concerns, people told us they were satisfied with the responses. Staff told us they were able to raise any concerns with leaders. Staff meetings included lessons learnt on incidents in the service. There was evidence of lessons learned from safety incidents. For example, where a piece of equipment had caused an injury to a person, an investigation and audit was completed, and all similar equipment was removed from the premises to prevent any recurrence. The provider had also introduced an adverse event debrief which allowed them to analyse incident trends more effectively by highlighting patterns in incidents. This enabled leaders to conduct root cause analysis of every event and apply learning across the whole service.

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. The provider had a pre-assessment form available which was used to capture people’s needs before they started living in the service. Most people told us there was an effective transition into the service. Where people needed to go to hospital, they told us the process went smoothly.

However, one person told us there were difficulties during the transition from hospital to the service, which was due to poor communication from the hospital and had since been resolved.

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. The provider shared concerns quickly and appropriately. People and their relatives told us the service was safe. One relative told us, “[Person] was definitely in a safe place.” On the day of our onsite visit, we observed there was a calm atmosphereand people appeared relaxed and at ease around staff. Staff understood their responsibilities in safeguarding people from harm and abuse and were able to tell us about the different types of abuse that could happen to people living at the service. Staff had received training in safeguarding and the Mental Capacity Act (MCA). Care plans contained relevant information to keep people safe. The provider kept a log of safeguarding concerns which highlighted actions and outcomes. There was a safeguarding policy in place to guide staff practice.

The provider did not always work well with people to understand and manage risks. For example, the service had identified a person who was at risk of pressure injury and according to their care plan needed regular repositioning every 4 hours. However, when we reviewed their care notes over a 5-day period between 12 July 2025 to 16 July 2025, records did not show the person was being repositioned every 4 hours. On one specific date, 14 July 2025, records showed the person had only been repositioned twice during a 24-hour period. There were also episodes over the 5-day period where records showed the person had not been repositioned over a significant length of time. For example, on one occasion, records showed a repositioning gap of 12-hours and on another occasion a 17-hour gap was identified. These gaps mainly occurred during the evening and at night. As a result, it was not clear if the person had been repositioned and therefore this placed a person at risk of skin breakdown, although we identified no harm had come to the person. In discussion with the service, clinical staff confirmed the person was being repositioned but told us this information was not always being recorded. Leaders told us they would look at how staff were recording this information in the future. We also identified one person with a pressure injury and the measurements of the wound had not being recorded by staff to monitor for any changes. This meant the provider was not able to monitor the wound shape and size to check it was healing or not. This was not in line with the provider’s Pressure Ulcer Assessment and Management policy which stated, “All pre-existing sores/ulcers should be photographed (with consent), measured and evaluated.” We fed this back to clinical staff on site, and they told us they would measure injuries in the future. Leaders were told about the concerns and confirmed they would discuss this with clinical staff to ensure action was taken in the future.

However, we saw people’s food and fluid charts were being completed and monitored by staff. People were also weighed regularly to monitor any weight gain or loss. Care plans and risk assessments contained sufficient information and there was evidence of good risk management communication in people’s risk assessments. For example, one care plan where risks had been identified in relation to a person’s behaviour stated, “When [Person] is agitated, restless, confused or disorientated, staff to monitor but please keep your distance, check pain levels of the person and do the pain assessment.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. People and their relatives told us they had access to the equipment they needed. One person told us, “I absolutely feel safe, I have had falls in past but not recently. They now use a hoist and its fine, the staff are trained.” People had access to call alarm bells in their rooms and in the communal areas, to call for help when needed. The service was in a good state of repair, although some people told us they did not have access to the outdoor area due to broken paving. Leaders told us people did have access to the outdoor areas such as via balconies, and there was wider work going on in the grounds at the time of our onsite visit, but this was subject to approval from the local authority’s planning permission team. Staff showed an awareness of what to do in an emergency and people had personal emergency evacuation plans (PEEPS) in place. Regular fire safety checks were being completed and there was a business continuity plan in place. The business continuity plan had identified alternative accommodation for people in the event of an emergency.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked well together to provide safe care that met people’s individual needs. People provided positive comments about staff and comments included, “They are very nice people, I am very happy here, the staff are very good,” and “I would say the staff are very efficient.” A few people told us sometimes there were language barriers, however, the provider told us staff had completed their relevant language skills tests and there was additional language checks completed during the recruitment process. The provider was also aware of concerns that had been raised about staff not speaking English with one another during their shifts and had spoken to all the staff to ensure only the English language was being used. Staff had regular supervisions and team meetings. A staff member told us, “Every month I have a supervision from my manager where they will tell me about my progress and areas where I need to improve.” Staff told us they received support and training in the areas where improvements were needed.

The required pre-employment checks had been completed for staff before they started work at the service. This included a check with the Disclosure and Barring Service (DBS). Staff also had the appropriate checks for the right to work in the UK. Staff had received a contract of employment, had clear job descriptions and completed an induction. There was evidence of staff receiving regular training in relation to their job roles. Regular spot checks and competencies were being completed by management where monitoring and observation of practices took place.

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 told us staff used personal protective equipment (PPE) where appropriate. People were generally satisfied with the cleanliness of the service. On the day of our onsite visit, we observed the service to be clean and there were no unpleasant odours present. We observed good hygiene practices such as staff using PPE, and there were hand-washing notices in communal bathroom areas for staff to follow. Hand sanitisers were located throughout the service and there were paper towels located in each communal bathroom. Staff had received training in infection prevention and control (IPC) and showed a good understanding of what they needed to do to ensure people were protected from the risk of infection. For example, one staff member told us, “We need to change PPE when supporting residents with washing, changing continence pads, oral hygiene, bed making, emptying a catheter and when there is a risk of clothing or being contaminated with blood or other body fluids." Regular IPC audits were taking place.

However, we identified one light pull cord in a communal bathroom area which had Sellotape around the bottom of the cord instead of a handle. The door to this communal bathroom also had dirty marks and was sticky to touch. These concerns could increase the risk of infections spreading. When we told leaders about these concerns, they provided evidence the pull cord had been immediately replaced, and the door had been cleaned. The manager told us, “I have noticed there are a few areas to be cleaned more thoroughly and when housekeeping staff complete their daily checklist, they provide this, and I now check daily.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. For example, on a review of room temperature logs, over a 3-month period between May 2025 to July 2025, the rooms used for the storage of medicines were consistently recording temperatures over the National Institute for Health and Care Excellence (NICE) guidelines. The guidance emphasises the importance of temperatures being 25 degrees Celsius or below in care home medicines storage rooms to maintain the integrity of medicines. The medicines audits identified the room temperatures were above 25 degrees Celsius and the service had added portable fans to the medicine rooms, but this had not brought the temperatures below the guidelines. This meant the provider could not be assured the medicines were fit for purpose at the point of administration to people. This concern was also identified at the last inspection in 2018 which had led to the medicines room being rearranged to address it. When we discussed this with leaders during this inspection, they acted immediately and relocated the medicines to a completely new room and added a portable air conditioning unit to maintain the room temperatures better. They also provided evidence of the new medicine storage room temperature for a 1-month period which was in line with guidelines.

We also identified a person who was living at the service and on end-of-life care did not have access to their pain medication the evening before the inspection because the syringe driver was not working. Staff told us another medicine had been given for pain relief, however when we checked these records, we identified the medicine was prescribed for agitation and not for pain relief. Although the provider replaced the broken syringe driver the next morning, it meant a person did not have access to their pain relief medicine for one evening. A review of the person’s care records did not indicate they had experienced any undue pain as a result of this.

However, people’s wishes and preferences were respected in relation to administration of medicines. Clinical staff responsible for medicine administration understood their responsibilities, they had also received annual training and regular competency checks were being completed. Regular checks were being completed on Controlled Drugs (CDs) stock levels and documented. As and when (PRN) medicine protocols were in place, reviewed regularly and were clear for staff to follow. There was a medicines policy in place.