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. At our last assessment we rated this key question Inadequate. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm. Previous breaches relating to safe care and treatment, safeguarding, safe staffing and robust recruitment procedures have been met since the last inspection.

This service scored 63 (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 now had a proactive and positive culture of safety, based on openness and honesty. Safety incidents, including falls, were investigated and reported appropriately. Records showed incidents were reviewed in a timely manner and where required, safeguarding referrals were made to the local authority and statutory notifications were submitted.

Risks were managed to support learning and improvement, and actions were taken to reduce the likelihood of recurrence. Debriefs were carried out with staff following incidents to reflect and learn from events. Learning from safety events was communicated to staff, who told us incidents were shared with them during handovers and team discussions. Staff explained this helped them understand what had happened and what actions were taken, so they could apply this learning to prevent similar occurrences.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Safety and continuity of care were now prioritised throughout people’s care journeys. This was achieved through a collaborative approach that involved people, staff and other professionals in planning and delivering care. Processes were in place to support safe referrals and admissions, including when people moved between services or accessed multiple services.

Systems and processes were in place to safeguard individuals from abuse and neglect. However, care plans did not always provide clear guidance for staff on how to escalate people’s allegations or concerns, to ensure they were reported appropriately and that prompt action was taken to keep the person safe.

People and their relatives told us they felt the service was safe. A person told us, "It's safe enough here." A relative stated, "Yes, [my family member] seems to be kept safe due to the staff, security is good.” Staff completed safeguarding training and understood how to recognise and report concerns and felt confident to do so.

Staff demonstrated awareness of the Mental Capacity Act 2005 and could explain how this was applied in practice. Authorisations for Deprivation of Liberty Safeguards (DoLS) had been sought appropriately; however, further support was needed to strengthen the understanding of the DoLS process in more complex cases to ensure restrictions were lawful, proportionate and kept under regular review.

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

Risks were assessed and documented, but involvement of people in these decisions was limited. Care plans contained risk assessments, although these did not always reflect a person-centred approach. People were not consistently supported to understand risks or how to keep themselves safe. While staff managed risks to prevent harm, opportunities for people to take carefully managed risks to maintain independence were not always explored. For example, a person was told to stay in bed until they had a healthcare appointment without evidence they had been consulted, whether this was necessary, or if there was another way to manage the risk. Another person told us, “I’ve got my walker, they set it up and walk by me if there’s enough staff on. I used to go the whole length of the corridor, but they say I’ve got to be more careful and have someone by me. So I’m in my chair quite a lot now.”

People were cared for in an environment that was generally safe, and the registered manager did regular visual checks to monitor risks. These checks identified issues, and improvements were ongoing, such as replacing flooring and redecorating rooms. Equipment was well maintained and available, and staff had received training in fire safety and manual handling to support safe care. Environmental risk assessments were now completed, and actions were taken promptly to address hazards. Emergency procedures were in place, including fire evacuation plans, and staff knew what to do in the event of an emergency.

Safe recruitment practices were now in place, and staff had mostly received training relevant to their roles. However, the provider had not ensured that all training met the mandatory requirements for learning disability and autism training. This was important to ensure staff had the right knowledge and skills to support people with a learning disability and autistic people safely and effectively.

The provider had implemented a staffing tool which improved their oversight and deployment of staff; however, we received mixed feedback about staffing levels.

Some people told us there were enough staff, while others said they experienced delays in receiving support, particularly at night and weekends. One person told us, “No, they don’t have enough, a few more would save long waits.” Another said, “They could do with a few more and they all seem capable enough. I notice they’ve stopped using agency much now. But they’ve cut down from 3 to 2 at night so you have to wait longer if you buzz.”

Other people were more positive, with 1 person saying, “I didn’t think they’re noticeably short-handed, and seem to be well trained,” and another commenting, “I’d say there’s enough from what I see.”

Systems were in place to manage the risk of infection. A recent external Infection Prevention Control (IPC) audit had been completed which showed improvements had been made, and new audits had been implemented following recommendations.

However, further improvements were needed. While the home was mostly clean and hygienic, some areas still required attention. For example, decoration and flooring were still being replaced to ensure surfaces could be easily cleaned and did not harbour germs. A relative told us their family member’s room sometimes had a strong malodour and that facilities were not always kept clean. One person commented, “My room’s kept clean, but I have to ask them to dust under my TV and ornaments now and then as it doesn’t get done.” Staff had received IPC training and understood when to wear personal protective equipment (PPE). A relative told us, “[The] home is kept clean and staff wear appropriate PPE.”

Food hygiene and food safety were well managed. Records were accurate and up to date, and food was stored, prepared and handled in line with best practice guidance.

Systems and processes were in place to store, administer and record medicines; however, they were not consistently followed. Temperature records for medicines requiring refrigeration were not completed in line with national guidance, meaning we could not be assured these medicines had been stored within the required range and were safe for use. This issue had been identified at the last inspection, indicating the improvements required had not been fully embedded.

People and their relatives did not raise any concerns about how medicines were managed. We checked stock balances for 10 people and found them all correct. Individual fire risk assessments were in place for people prescribed paraffin-based skin products which helped reduce the likelihood of serious harm by identifying hazards and implementing controls. Instructions for medicines that should be given at specific times were available, reducing the risk of adverse effects.

Processes were in place for medicines administered via patches, including recording application sites to prevent repeated use on the same area. Guidance was available for medicines administered through stomach feeding tubes (PEG) and for 'as required' (PRN) medicines. Thickeners were recorded when used, and handwritten medicine administration records (MARs) were signed by 2 staff. Topical creams were recorded with body maps, and controlled drugs were managed in line with national guidance. Staff had completed medicines training, and competencies were regularly assessed. This was important because it ensures staff had the knowledge and skills to administer medicines safely and correctly.