Woodlands Court 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. This is the first assessment since the service was re-registered under a different provider name. This key question has been rated 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, reported safety events but did not always investigate these fully. Lessons were not always learnt to continually identify and embed good practice.

We asked people and relatives about their experiences of how accidents or incidents had been managed. A relative told us, “When [relative] first came, they fell out of bed several times. They tend to lean to the left when in bed, so they [staff] moved the furniture round so that the bed is now positioned so they lean towards the wall.”

A log was used to document any incidents or accidents. Alongside this was a separate log for recording any lessons learned. Although each incident had been recorded, there was limited information about what actions had been taken, whether this had been successful and what the provider would do differently moving forwards, to minimise the risk of a reoccurrence.

From reviewing provider records we noted a high number of minor accidents, incidents and falls with no injury had occurred over the last 6 months. We found limited evidence analysis had been completed, to look for patterns and trends to try and reduce the frequency of these. The provider took steps to address this during the assessment.

A process was in place for managing any accident, incident or fall. When asked, staff were aware of this. One told us, “We complete a full body and limb check, fill out an accident form, complete the 72 hour observation form, ring the family, and depending on how serious it is, ring ambulance or 111.” Pre-admission falls questionnaires had been completed, to assess risks and identify if any aids were required. This ensured staff had the information they needed to keep people safe.

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 worked closely with commissioners and other stakeholders, such as social workers, to ensure people’s transitions into and out of the service were successful

The provider used a ‘transfer to hospital’ document, which was sent with people being admitted to hospital, whether short or long term, to help ensure continuity of care. This document was a mini care plan, which explained their likes, dislikes and how they wanted to be supported, as well as key information on any risks hospital staff needed to be aware of.

We asked the registered manager about the process for supporting people to transition between services, whether this was into or out of the home. They told us, “We work with the transfer of care hub, trusted assessors and social care teams, to complete assessments and obtain referrals for people to move into and out of the home; I feel this this works well.”

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 told us they felt safe living at the home and when receiving care. One person stated, “I am safe, they are great carers, the security is good and they always put my Zimmer frame close to me, so I can get around.” Another said, “‘I am very safe. I settled in here very quickly, because I felt everyone was looking after me well.”

Relatives also spoke positively about the safety of their family members. One said, “Is mum safe? Definitely, she gets all the care she needs and they keep her safe”. Another relative stated, “We both feel he is safe here, much more so than when he was at home. His dementia progressed very quickly and he lost his ability to look after himself. He responds well to the carers, and they appear to understand his dementia needs.”

The home had appointed a ‘What’s Up Champion’. The ‘What’s Up Champion’ programme is an initiative introduced across care homes in Wigan by Wigan Safeguarding Adult’s Board. Champions are people living at the home, who support other people in the home to have a voice. They help people talk about any concerns and raise safeguarding issues.

We found safeguarding concerns had been reported in line with local authority guidance. Wigan Safeguarding Adults Board use a Tier system, the higher the Tier number the more serious the incident or allegation of abuse. CQC expects providers to notify us of any referrals which are Tier 3 or higher. In the last 12 months, we received 1 safeguarding notification from Woodland Court. However, the providers safeguarding log indicated they had submitted 11 Tier 3’s to the local authority. After reviewing these with the registered manager, we found 10 had been downgraded to Tier 2, which is why notifications had not been submitted. However, this information had not been documented on the safeguarding log, which lacked detail. The provider took steps to address this during the assessment.

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.

Where possible, people had been involved in discussions about keeping them safe and managing risks. One person told us, “I have a pressure mat so the staff know if I stand up as I am in danger of falling; carers also pop in my room all the time.”

Care plans contained a number of individual and generic risk assessments, which provided staff with information and guidance on how identified risks should be managed to keep people safe from harm or injury. These were reviewed periodically to ensure they remained effective and met people’s changing needs.

As part of the assessment process, the provider completed safe handling assessment forms. These detailed people’s health needs, the person’s understanding of their needs, their care preferences and what makes them upset or anxious when being supported to transfer or be hoisted. This ensured a person centred approach to managing people’s mobility risks was maintained.

Each person had a personal emergency evacuation plan (PEEP). These are used to provide guidance for staff on the support each person needs to safely evacuate in an emergency.

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

Risk assessments of the environment and equipment used within the home had been completed, to ensure these were fit for purpose and used correctly. Ongoing safety checks had also been completed in line with legislation, with certification in place to confirm compliance. This included checks of gas and electrical safety and equipment such as the passenger lift and hoists. An up to date fire risk assessment was in place. We saw issues identified during the fire risk assessment process had been addressed in a timely manner.

The provider had an up to date contingency plan, which explained what action would be taken in an emergency, for example if the home were to have no power, heating or access to water. This included alternative accommodation if the home was temporarily uninhabitable and details of how people would be transported there.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support and development, although a consistent staff supervision process had only been implemented in the last 6 months. The provider and staff worked together to provide safe care that met people’s individual needs.

Overall, people and relatives told us enough staff were deployed to meet their needs and provide safe care. Staff were reported to attend to requests for help timely, although some people reported wait times at night were much longer, and thought more staff at this time may help. One person told us, “I think there are enough; they are always in the lounge and carers walk around at night.” Another person stated, “I don’t feel there are enough staff between 7pm and bedtime. If I buzz for help during these hours it takes a long time for anyone to get to see me.” A relative stated, “When we visit there appears to plenty of staff on hand; we have no concerns about staffing ratios.”

Staff also provided mixed responses when asked about staffing levels. However, this was mainly linked to colleagues phoning in sick and leaving shifts temporarily short until cover had been found. One staff member stated, “When all the staff turn in, you can manage. You are never still, always on the go, but can manage. The problem is getting staff to turn in reliably. Sickness is an issue here.”

The provider used a system for determining how many staff were needed to meet people’s daily care needs. We found staffing levels were based on this information, with rotas showing the correct number of staff had been deployed during both day and night shifts.

Staff spoke positively about training, confirming the induction training process was detailed and regular ongoing training was provided to ensure their knowledge remained up to date. One stated, “I had an induction, consisted of about 15 e-learning courses. I completed shadow shifts for a few weeks. Once my DBS came back and I felt confident, I started to work more independently.” Another told us, “We get quite a lot of training. We have online and some paper- based training within the home. If you are unsure of anything, there is always someone to ask for help.”

Staff feedback suggested supervision was inconsistent and infrequent. The provider’s policy stated staff would receive 4 supervision sessions per year. However, the matrix for documenting completion had only been implemented in January 2025, so we were unable to confirm how many had taken place in the last 12 months. The registered manager told us they had identified supervision had not been held consistently when they commenced the role, so had taken steps to address this, which included introducing the current matrix.

Staff were recruited safely, with all required pre-employment checks completed and references sought.

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.

We found the home to be clean, with robust infection prevention and control (IPC) processes in place. We observed housekeeping staff throughout the home, with checklists and records in place to evidence good cleaning practices. The home had IPC information displayed on each floor including information on handwashing and use of personal protective equipment. We noted colour coding for cleaning equipment was utilised, to reduce risk of cross contamination.

People’s feedback supported our observations. Comments included, “Everywhere is clean all the time; the cleaners do a great job. My laundry and bedsheets are washed very regularly” and “The home is spotless. My room is cleaned every day. The staff never touch anyone without gloves on.”

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

We identified some issues with the safe management of medicines. Medicines audits completed by management had identified some of the shortfalls we found, however, action to address these was slow to take place, with the same issues appearing on consecutive audits.

When checking the homely remedies box; these are over the counter medicines most people would have at home, such as paracetamol and simple cough linctus, we noted a number of paracetamol tablets had been administered but not documented. As such, the provider could not confirm who had had these and when.

Where people took medication which had a sedative effect, risk assessments had been completed. These stated 30 minute checks were to be completed after administration due to an increased risk of falls. Although staff told us these checks were completed, they had not been documented consistently.

Where people were prescribed time sensitive medicines, such as to be given an hour before food, the exact time of administration was not recorded, which is best practice.

People were happy with how their medicines were managed, telling us they received these when they needed them. Comments included, “They give me medication morning and night. They watch me take it” and “They are very reliable; I get my medication every day.” We found people’s prescribed medicines had been administered timely and consistently.

Guidance was in place where people had medicines to be taken as required such as pain relief. These explained what the medicine was for, how much to give, how often and if the person was unable to state they needed the medicine, what signs staff should look for. This ensured these medicines were administered safely and effectively.

Medicines were stored safely and effectively. Fridge temperatures had been recorded consistently, to ensure medicines which needed to be stored at a certain temperature remained effective.

Staff who administered medicine, received training and had their competency assessed.