Woodlands 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. The last rating for this key question was good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of legal regulations relating to safe care and treatment, safeguarding service users from abuse and improper treatment and staffing.

This service scored 34 (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 not always ensured safety was a top priority that involved everyone. Serious risks to people’s safety and wellbeing had been overlooked and were only addressed after these were identified by CQC.

However, the provider had a culture where staff learnt from incidents, accidents and things that went wrong. These were recorded, investigated and discussed to help make sure improvements were made. People’s relatives told us the staff had responded appropriately after people had fallen and they had taken steps to help prevent further accidents.

The provider had not always ensured people had safe transitions between services. During refurbishment of the care home, the provider moved some people into unsafe and unsuitable places. They told us they had consulted with family members. However, they had not consulted with other professionals. The provider moved 6 people into a property which was not part of the registered care home. To ensure people’s safety, we imposed conditions on the provider’s registration which meant they had to reduce the number of people they were allowed to care for, including these 6 people and 2 others. The provider worked with other professionals to help support a safe transition for these 8 people to their new homes.

The provider had procedures to help safeguard people from abuse. However, people were not always kept safe. The provider made some decisions about people’s care without consulting all the relevant people who should be involved in these decisions. These decisions had led to restrictions on people’s freedoms and human rights. Some decisions had also exposed people to the risk of abuse. These had not always been made in people’s best interests or in the least restrictive way.

The registered manager told us they had gained consent from family members to move people out of their home, to move some people into shared rooms and for male staff to carry out intimate personal care for females using the service. However, they had not always made these decisions in people’s best interests or considered other alternatives.

Additionally, they had not consulted with the authorities who commissioned people’s care or the supervisory body responsible for issuing and monitoring Deprivation of Liberty Safeguards (DoLS). DoLS are a set of checks that aim to protect people who lack the mental capacity to make decisions about their care.

The local authority was concerned about the way in which changes to care services had taken place and how these impacted on people. They identified potential abuse and were in the process of investigating this using their safeguarding processes. The provider was engaging with this process.

Although we identified the concerns above, we found that staff undertook training to understand about safeguarding adults and they had opportunities to discuss the processes for recognising and reporting abuse.

The provider did not have appropriate procedures to assess and plan for risks relating to fire safety. They had not carried out a comprehensive fire risk assessment. They did not have an up-to-date general evacuation plan and personal emergency evacuation plans (documents used by providers to assess the risk and plan for people to evacuate in the event of an emergency) were not personalised and had not considered individual needs and circumstances. Furthermore, documents to help ensure emergency services could locate and support people were not readily available.

We considered the potential risks to people as extreme and took urgent action. The provider was required to undertake a comprehensive assessment and make personalised plans to ensure individual people could be safely supported in the event of an emergency. They took the required action, and we were satisfied the risks were reduced.

The provider did not ensure risks relating to people’s care and wellbeing were appropriately assessed, monitored or managed. The provider had made extensive changes to the layout of the environment and where people spent their time. They had not reviewed or updated risk assessments in relation to this and therefore, they had not always effectively planned to mitigate these risks. People were exposed to environmental risks. Additionally, the risks relating to their mental wellbeing and health had not been reassessed or planned for to consider the impact changes in the service may have had. For example, the care plan we viewed for 1 person stated, “[Person] is confused and anxious due to cognitive impairment and change of environment.” However, there was not a personalised plan about how this person should be supported.

Individual risk assessments were not always detailed enough or personalised. They did not always include personalised information about the risk to the person, their perspective and capacity relating to these risks, external factors that might affect the risk or include a comprehensive strategy for managing these. For example, the ‘moving and handling’ assessment for a person did not include any details about past risks or falls, did not include information about their anxieties or feelings and the only strategies were ‘staff to supervise’ and ‘walks with a frame.’ The computerised assessment system used by the provider included standard generic statements and there was not always additional information about how to manage the risk for the individual. One person was identified as at high risk of fractures. However, the only recorded management plan in respect of this was, “Offer lifestyle advice and refer to doctor for treatment options.”

The provider did not always ensure people lived in a safe environment. The provider was in the process of refurbishment. They did not have effective plans for managing fire safety including safe evacuation plans, detection systems or emergency lighting. We identified serious risks to people’s health and wellbeing and took urgent enforcement action to impose conditions on the provider’s registration. As a result of our action, the provider was required to take additional steps to ensure safer systems for preventing and detecting fires and plans for emergency evacuations. We shared our concerns with the local authority who arranged for a fire officer to visit.

We identified other concerns within the environment which included, an air flow mattress plugged into an extension lead which trailed across a bedroom floor and the use of unguarded portable heaters plugged into extension leads and used in rooms where people lacked the mental capacity to understand the risks associated with these. Fire exit routes were not always clear of hazards. One route contained a hoist, mattresses, other furniture and a loose piece of carpet which presented a trip hazard.

There were restrictions on people moving around the environment due to building works. The staff told us that 2 people liked to move around independently, but were unable to safely do so without staff at the time of our assessment.

The provider had not always deployed enough staff to keep people safe or meet their needs at night. At the time of our visits to the service, 17 people lived in 3 different areas of the service. Staff and people could not move between these different areas without going outside. The provider had employed 3 members of staff to work at night meaning that each member of staff was allocated to a different building. Some people required 2 members of staff to support them with personal care. Records showed that all 17 people required staff support to safely evacuate in the event of emergency. Ten people required mobility aids to move safely and 3 could not move out of bed without hoisting. The staffing levels were not safe. We took urgent action to impose conditions which meant the provider was required to reduce the number of people they cared for. They were also required to use a tool to calculate staffing levels accurately.

People’s relatives told us they felt there were enough staff working during the day, although some felt staffing levels did not allow for people to access certain activities.

The provider had appropriate procedures for recruiting staff. These included checks on their suitability, skills and knowledge. New staff completed an induction into the care home and undertook a range of training. Staff told us they had regular meetings with the management team.

The provider had procedures for preventing and controlling infections. However, these were not always followed. During each of our visits we identified some areas where improvements were needed. These included waste bins that were overflowing, inappropriate storage of slings which were used to move people, no facilities for sluicing or clinical waste disposal in some areas of the service and a person’s wash basin which was full of dirty water and could not drain. We discussed our findings with the management team so they could take action to address these issues.

People using the service and relatives told us they thought the service was clean and that staff wore personal protective equipment (PPE) such as gloves and aprons when needed. Their comments included, “I think it is clean and hygienic”, “I have seen the staff using gel, aprons and gloves” and “They always put gloves and aprons on. They come and sweep up after mealtimes and wipe down tables.”

A staff member was responsible for both laundry and housekeeping, and we observed cleaning staff at work. The lounge, which was occupied most of the day, was cleaned by night staff, when people were in their rooms. There was a set cleaning schedule and audits of cleanliness and infection prevention and control.

The provider had not always ensured medicines and medical treatments were safe and met people’s needs, capacities and preferences.

Some people were administered medicines covertly (without their knowledge). The staff had not followed national guidance to ensure this was done safely. They had consulted with a doctor and next of kin. But they had not sought input and guidance from the pharmacist about how to safely crush or mix medicines with food and drink.

Staff did not always check or record the medicine fridge temperature accurately. This meant they were not able to identify whether medicines were stored at the correct temperature. Failure to do so could lead to problems with the effectiveness and safety of these medicines.

The care plans for medicines were not always person-centred. Also, for 1 person there was no care plan in place regarding their health needs. There was not enough detailed information about the use of as required (PRN) medicines. Protocols for these and care plans were not detailed enough to ensure medicines were administered safely or consistently.

Audits of medicines management had failed to identify where improvements were needed.

We observed staff administering medicines in a safe way. The staff kept accurate records to show they had administered medicines. Medicines were stored securely. The staff undertook training to understand how to manage medicines safely. The management team assessed their knowledge and competences. The local GP carried out reviews of medicines management. There was a process for reporting and investigating medicine errors and incidents.