Woodview Care Centre

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 provider of this service changed. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulation in relation to safe care and treatment, safeguarding, safe staffing and robust recruitment procedures.

This service scored 38 (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 have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff had not always completed accident forms appropriately or in a timely way which impeded the ability to learn lessons to minimise the risk of reoccurrence. For example, when people had falls, forms were often incomplete with missing information to show contributing factors to the falls, how falls might have been prevented or could be in the future. Debriefs were not completed with staff to discuss what had been done well or what could have been improved to control the risk more effectively. This meant there were missed opportunities to identify areas for improvement to increase people’s safety and minimise risk of injury.

The provider did not always make sure there was continuity of care, including when people moved between different services.

People’s care plans were not consistently up to date with the most relevant information and risk assessments were not always carried out when necessary. This meant if a person needed to go to hospital or transfer to another service, the person was at risk of not being safely supported in line with their needs and preferences.

The provider’s electronic system had the ability to print off emergency hospital packs, however, night staff did not have access to the printer, so they were unable to print them off if someone needed to go to hospital at night. This meant hospital staff would not have an overview of the person’s needs and preferences which would be essential if the person was unable to express their wishes or make decisions themselves.

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

Staff understood their safeguarding responsibilities; however, they had not always raised concerns in line with the provider’s policy to ensure suspected abuse was appropriately reported and investigated. A person told us they had experienced abuse and reported it to staff, but nothing had been done.

Although some people told us they felt safe, other people told us they had concerns about staff. A person told us, “Some staff are a bit on the rough side. I will tell them if they hurt me though.” Another person told us, “I find they’re bossy with me. It’s the fear they put up you.”

There was a lack of open communication and external scrutiny, which increased the risk of harm and abuse. For example, when a person was found to have unexplained injuries, the acting manager accepted staff explanation rather than considering a range of possibilities and reporting it to the local safeguarding team. The provider was not always transparent when things went wrong. When a person was injured from unsafe staff support, this was not referred to the local safeguarding team to protect people from harm and ensure measures were taken to improve the quality and safety of the service.

When people were known to make allegations against staff, this was not documented appropriately in their care plans and risk assessments had not been carried out to ensure staff knew to report all concerns regardless of past unfounded allegations.

Deprivation of Liberty Safeguards (DoLS) were not always appropriately in place to protect people’s human rights. DoLS is the procedure prescribed in law when it is necessary to deprive of their liberty a person who lacks capacity to consent to their care and treatment in order to keep them safe from harm. A person under a DoLS authorisation objected to their current residency, however, the process to determine whether the objection was valid had not been followed.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans did not give clear guidance on how to support people in line with their assessed needs, which meant they were at risk of inconsistent and unsafe support. For example, a care plan did not give enough detail on how to support a person with their continence to achieve good physical health and reduce the risk of any skin damage.

The provider had not carried out risk assessments when risk had been identified. This meant steps had not been taken to keep people safe and free from injury alongside enabling them to make risk choices when possible. For example, a person living with dementia regularly entered other peoples’ bedrooms which had caused distress. Although the management team were aware of this and understood the risk, they had not assessed the risk or put any control measures in place to keep people safe. A person told us, “The only time I don’t feel safe is when [people living with dementia] are around and might come into our rooms again and disturb us.”

Some people were having multiple falls and actions were not taken following falls to ensure current measures in place were sufficient to mitigate or minimise risk of reoccurrence. Equipment to reduce the risk of falls was not discussed with people and their relatives to ensure they could make informed choices about whether they wanted to use it or not. This meant people were at risk of recurring falls and potential serious injury.

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.

Environmental checks and maintenance were completed. We saw regular checks had been carried out to ensure the home was safe in the event of a fire and emergency, however actions identified by the provider were not put on action plans to show they had been completed or delegated to an appropriately qualified person to make safe. For example, shortfalls had been identified during the evacuation drills, however there was no evidence any actions had been taken to improve the safety of the service.

The provider had not always maintained the building to a high standard. Flooring in several areas of both units required replacement. Although the acting manager stated they were waiting for this to be signed off by the owner, the condition of flooring had been raised as a concern by the CQC in 2023 and by the Health Protection team in 2024. Several areas required repair and repainting as they could not be cleaned effectively due to damage.

Environmental risk assessments were not completed to ensure risks were identified, assessed and controlled. For example, risks associated with the storage and use of substances hazardous to health (COSHH) had not been assessed to ensure people and staff were kept safe from harm.

The provider had not reviewed the fire risk assessment to ensure it remained relevant, accurate, and compliant with regulations to help maintain a safe and healthy environment for people and staff.

Personal emergency evacuation plans (PEEPS) did not include enough detail to safely evacuate people. Plans contained basic information and did not consider peoples’ cognitive capacities or how a person might react to an alarm sounding and being evacuated, including the support they may have required after evacuation to keep them safe. There was no information on where the equipment needed to evacuate people was kept. In an emergency, staff may have been unable to locate the equipment to safely evacuate people which put them and staff at risk.

Although people and their relatives were mostly satisfied with the cleanliness of the service, we noted some malodours in the afternoon and the floors in communal toilets were not cleaned regularly to ensure they were free from debris and kept hygienic. A relative told us their family members room could smell of urine because it had carpet which was not appropriate for their needs.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Staffing levels had not been reviewed regularly to ensure there were enough staff even though there had been changes to the people who lived at the service. This put people at increased risk of neglect and abuse.

People and relatives raised concerns about the lack of staff. A person told us, “They’re often short as I have to wait longer for help. The weekends they’re a bit shorter.”

Staff received training in line with their role, however, the provider had not ensured that training in Learning Disabilities and Autism which is required by law was completed by all staff. Staff did not receive regular supervisions in line with the provider’s policy. Although staff told us they felt supported, we found staff needed further support to understand and work in line with expected standards. Not having a structured, regular process with a supervisor increased the risk of compromised care quality.

Recruitment checks were carried out to ensure staff were suitable to work at that type of service. However, the provider had not gained full employment history of staff to confirm their suitability for the role. There was a process to check staff’s continued eligibility to work in the UK when they had time-limited right to work in the UK. However, this was not always being followed to ensure checks were being made in the right timescales. Failure to recruit staff safely, including failing to conduct thorough background checks can significantly compromise the safety of people and staff.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Daily cleaning schedules provided no guidance for staff on what they were required to do, which meant it was open to interpretation. Domestic staff told us how they completed tasks, but there was no clear and consistent standard. An hourly contact point clean was being intermittently completed by domestic staff who told us they did it as and when they could within their shifts. The acting manager told us they were not aware it was being completed and stated they only expected them to do that if they were in an outbreak.

Laundry facilities did not have a dirty to clean workflow system, so that clean and soiled linen could be physically separated throughout the process. All dirty linen should be handled with care and attention to prevent the potential spread of infection.

Staff understood their responsibility to use appropriate personal protective equipment (PPE), and domestic staff had a good understanding of their role in relation to potential outbreaks of infectious diseases.

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.

Systems were in place to safely store, administer and record the use of medicines. However, temperature records to ensure the safe storage of medicines were not completed in accordance with national guidance. This meant we were not assured that medicines requiring refrigeration were safe for use.

Instructions for medicines which should be given at specific times were available. Administering medicines as directed by the prescriber reduces the risk of the service user experiencing adverse effects from the medicine.

Detailed guidance specific to each person on how to administer medicines prescribed as and when people required them, known as ‘PRN’ was available to staff.

Some people were unable to take their medicines by mouth. Guidance was in place to enable trained staff to safely administer appropriately prescribed medicines into a stomach tube (Percutaneous endoscopic gastronomy, also known as PEG).

There were appropriate arrangements in place for the management of controlled drugs (medicines that require extra checks and special storage arrangements because of the potential for abuse). Records showed that staff completed regular balance checks in accordance with national guidance.

Staff told us they had completed a training and induction process for medicines management and staff competencies were assessed regularly to ensure they had the necessary skills.