Woodley Hall 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 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 regulations in relation to safe care and treatment and had failed to notify CQC of notifications as required by legislation.

This service scored 59 (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 identify and embed good practice.

The service had systems in place for reporting, recording and monitoring accidents and incidents. These were regularly reviewed to identify patterns and trends, and lessons learned were shared with staff to improve practice and reduce the risk of recurrence.

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.

Before people moved into the home, an assessment of their needs was completed to ensure the service could meet their care and support requirements. Relevant information was available should a person need to be admitted to hospital. This helped ensure important details about people’s health, preferences and support needs were clearly communicated, promoting continuity of care during their hospital stay.

The provider worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They concentrated on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. However, the provider did not always share concerns quickly and appropriately.

There was not an effective system in place to ensure safeguarding alerts, as required by the provider’s registration, were reported to the CQC. For example, when we reviewed safeguarding records, we found evidence of alerts that had been reported to the local authority but not notified to the CQC. The registered manager told us they were not aware of this requirement but confirmed they would address this immediately.

People were supported by staff who had the knowledge, training and confidence to recognise safeguarding concerns and take appropriate action to protect them from the risk of harm or abuse. A staff member told us, “If I ever had concerns about care, I would report them to the senior on duty or the manager, and I know how to raise a safeguarding alert if necessary.”

The provider did not always work effectively with people to understand and manage risks to their safety and wellbeing. Staff did not always have access to up-to-date or sufficient information to enable them to provide care that met people’s individual needs.

Whilst care plans were person-centred, they did not always contain detailed information about the specific support people might require. For example, for people identified as being at risk of self-harm, care plans did not include information about items that could present a risk or guidance for staff on how to respond if they encountered the person harming themselves. This meant staff did not always have the information needed to provide consistent and safe support to minimise the risk to people’s wellbeing.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Regular health and safety checks, including electrical, gas and water safety, were completed. Care equipment, such as moving and handling aids, was routinely serviced. Staff received appropriate training to ensure they could use equipment safely when delivering care.

However, there was a lack of documented checks on the emergency fire grab bag to ensure that both equipment and accompanying information were current and functional. When we checked the bag, several items were not in working order. As a result, staff may be unable to respond effectively in an emergency, creating a potential risk to people’s safety.

The provider did not always make sure there were enough qualified, skilled and experienced staff.

Recruitment and staff management processes were not always robust. Gaps or missing information on application forms were not consistently followed up at interview. One staff member recruited under the Certificate of Sponsorship scheme had documents managed centrally, with no apparent involvement from the registered manager. Nine months after recruitment, the relevant documentation had not been provided to or retained by the registered manager.

There were also two instances of internal recruitment or role changes where processes were unclear. For the promotion to senior carer, there was no evidence that the opportunity had been made available to other staff, and the registered manager could not explain the decision. There was also no record in supervision or one-to-one meetings of any discussion regarding the member of staff’s skills, abilities, or development prior to the promotion. For a staff member returning to work following illness, there was no documented discussion about reasonable adjustments in their return-to-work record.

Interview records were not always fully completed, which could compromise the provider’s ability to demonstrate consistent, fair and safe recruitment practices.

Staff received regular support, supervision and development. Records of staff supervision were maintained on an online system and included both regular one-to-one supervision and additional sessions on specific topics, such as bowel care. All staff files reviewed contained records on the system. A chart in the manager’s office showed planned supervision allocation, with specific topics for discussion each month and a recommended frequency of every two months.

However, from the records reviewed, there was little evidence of staff contribution to supervision. Although there was a space in each record for staff input, only one record contained an entry from a staff member. When asked, the registered manager thought staff did not have access to the system to reflect or add comments outside of supervision sessions, meaning the process appeared largely one-sided.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Processes were in place for the prevention and control of infection, and audits had been completed. However, parts of the building were not consistently clean. Paintwork around door frames was chipped, making it difficult to clean in line with infection prevention and control (IPC) guidance. On some days, only one housekeeper was on duty, and we observed them also providing care to people, which could affect cleaning effectiveness.

We also observed staff wearing masks under their chins, which is not in line with IPC guidance. Gloves and disposable aprons were not always stored appropriately; some gloves were placed on top of the apron holder and on handrails. Other items, such as the fan in the lounge on the ground floor and the air conditioning unit in the medicines room, were dusty and had not been cleaned. Bathrooms needed repair, with damaged flooring and bath surrounds, and cluttered storage for disposable items.

A daily cleaning checklist was in place, the most recent available being for 3 October 2025. Completion appeared inconsistent, as did records of deep cleans. IPC audits completed between January 2025 and October 2025 showed compliance ranging from 98% to 100%, with no actions identified, despite the issues observed during our assessment.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The service had appropriate systems to ensure that medicines were stored, administered, and disposed of safely. Records confirmed that individuals received their medicines as prescribed and in ways that suited their personal preference.