Woodland Grove

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 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 provider was in breach of a legal regulation in relation to governance.

This service scored 56 (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 foster a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice. There was a system in place to record accident and incidents. While we were assured the necessary action was taken immediately following incidents to ensure people’s safety and wellbeing, we found follow up actions were not always completed in a timely manner and lessons learnt were not always well recorded. For example, when a person experienced recurrent episodes of emotional distress, we found delays in the development of effective strategies to reduce the risk of these incidents recurring. Staff told us they felt unclear on how to manage this specific situation and, although no harm had occurred, they described an increased frequency of incidents. Relatives told us they sometimes felt “disappointed” when issues were not resolved in a timely manner.

We shared our feedback with the registered manager who was open and honest with regards to delays in the positive behaviour support team becoming involved to develop strategies to help reduce the risk of recurrence. We were assured a review had been initiated and work towards effective strategies was underway.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. Electronic records of people’s individual care were kept. Staff told us how they could easily download essential information about people’s needs if they needed to be admitted to hospital to ensure continuity of care. The provider worked closely with professionals to ensure people’s health and social care needs were monitored and managed. Professionals spoke positively about how staff worked in collaboration with them. Comments included, “Our communication channels work well, [Staff] respond quickly to any queries I may have. They update me in a timely manner regarding any changes to [Person’s] presentation or areas of concern."

The system in place to monitor and ensure the appropriate legal processes were followed for the use of restrictive practices were not always effective. Mental capacity assessments were not completed for all restrictive practices such as equipment used for continuous monitoring and equipment used to restrict a person’s movement. The correct process under the Mental Capacity Act 2005 (MCA) had not been followed to ensure the restrictions were proportionate, used in the person’s best interests and to ensure they were safeguarded from abuse. We shared our feedback with the registered manager who took action to review the relevant mental capacity assessments.

However, the provider understood their safeguarding responsibilities to share concerns with the local authority. Staff received safeguarding training and they could confidently describe the action they would take to protect people from harm. Relatives felt confident their loved ones were safe in the care of staff. Comments included, “I feel [Person] is safe, they take safety very seriously” and “They make sure [Person] is safe and looked after, anything happens I am always informed."

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Overall, people’s individual risks were assessed and personalised care plans were in place to guide staff on how to mitigate risks to people’s health, safety and welfare. Staff knew people well and could describe the action they took to reduce risk and keep people safe.

The provider did not always detect and control potential risks in the care environment. They did not make sure facilities supported the delivery of safe care. The provider failed to act upon risk information shared by external professionals to mitigate risks to people’s health and safety. The provider had instructed an external consultant to undertake a fire safety risk assessment in November 2025. This identified concerns in relation to fire doors that would be ineffective in preventing smoke spread and the unsafe storage of combustible items. We were not assured action was taken following this assessment as our observations of the environment found the same hazards remained. The lack of action taken exposed people to an avoidable risk of harm.

The registered manager was responsive to our feedback and took immediate action to improve fire safety standards. They provided an action plan which showed remedial works had been arranged with fire doors due to be replaced soon after the assessment and put a risk assessment in place in the interim to reduce risk.

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 that met people’s individual needs. Staff were safely recruited. The required background checks, induction and shadowing opportunities were completed before staff started working independently. Enough staff were deployed to meet people’s needs, and we saw the support was generally consistent. During periods of low staffing, the registered manager arranged cover from agency staff. We saw how they had worked to reduce the number of agency staff used in recent months to ensure continuity in people’s care.

Staff undertook a range of training the provider deemed mandatory. We were assured the training provided staff with the necessary skills to care for people with a learning disability and autistic people effectively and was in line with best practice guidance. Relatives provided positive feedback about staff skills and experience. A relative told us, “They understand autism well and in-depth and are fully committed to providing [Person] with life experience."

The provider did not always ensure systems were operated effectively to assess and manage risks relating to infection prevention and control (IPC). Our observations found concerns with the cleanliness of people’s living environment such as communal areas, people’s bedrooms and both bathrooms. The concerns included unclean floors, unclean sealants in bathrooms, unclean windows, sills and handrails and radiator covers had multiple areas of chipped paintwork. Although a cleaning schedule was in place, we were not assured effective cleaning had always taken place based on our observations and multiple gaps within the records.

Some relatives felt improvements were needed to the cleanliness of the environment. A relative told us, “[Staff] haven't got time to get into corners, the bathroom floor needs updating, it’s very grimy and needs changing. Non-slip matts need to be washed more.”

We shared our findings with the registered manager who responded positively. They shared an action plan outlining how they would improve IPC practices overall and evidence provided assured us some of the issues had been resolved shortly after the assessment. They shared their plans for refurbishing the bathrooms and kitchen.

Systems in place to ensure the safe management of medicines were not always implemented effectively. For example, when medication errors occurred, action plans were put in place to ensure staff were subject to a medication competency assessment prior to administering medicines again. We found these actions were not always completed in a timely manner.

While we were assured people received their medicines mostly as prescribed, we found some medicines were given at a time inconsistent with the prescriber’s specific instructions. For example, a medicine to be given at night was given at teatime. Records were not kept regarding the reason for this change, and a rationale could not be provided by the registered manager or staff.

The registered manager and team leaders took swift action to contact health professionals regarding some of the inconsistencies with the medicine timings. Health professionals provided reassurance people would not come to harm for the medicines being given earlier. However, we discussed with the registered manager the importance of good governance in relation to medicines and keeping accurate records to provide justification for medicines being given against the prescriber’s instructions.

Staff received training in medicines, and our observations of medication administration practice found staff carried this out in a safe and person-centred manner. Staff completed robust checks to make sure people were receiving the correct medicines.