Amy Woodgate

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 for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider had developed a positive learning culture within the care home. People were encouraged and supported to raise safety concerns with managers and staff. Managers and staff understood the importance of reporting safety concerns. Systems were in place to support staff to report and record safety concerns and events when they arose. Any safety concerns or incidents that did occur were investigated and when lessons needed to be learnt this was used to continually improve staff practice. The deputy manager told us, “We are constantly learning and trying to improve the service we provide people here. I would say that’s the underlying principle of the homes culture.”

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.

Managers gathered information about people’s individual needs and wishes, and risks to their safety, prior to them using the service. This information was used to develop person-centred care and risk management plans which were shared with staff to help them provide safe and appropriate care to people from the moment they started living in the care home. Managers and staff worked closely with all the relevant family members where applicable and external health and social care professionals and bodies to ensure care plans and risk assessments reflected people’s current needs and wishes.

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 in the care home. One person said, “I feel safe living here. The staff are always friendly and know how to look after us.” A relative added, “My [family member] is kept safe here by all the brilliant staff.” Managers and staff understood how to safeguard people. They knew how to recognise and report abuse and were able to articulate how they would spot signs if people were at risk of abuse or harm. A member of staff told us, “I’ve had safeguarding training. I know what abuse is and that I must report it to the managers or staff in-charge immediately if I ever see it happen to any of the residents who live here.” Managers worked proactively with the relevant agencies, when a concern was raised, and took appropriate action to safeguard people from further risk, when this was required.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (Dols), which is part of the Mental Capacity Act 2005 (MCA). Managers and staff liaised with the relevant local authorities to ensure appropriate DoLS arrangements were in place to ensure people’s safety.

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.

Systems were in place to ensure risks to people were routinely assessed, monitored and reviewed. People’s care records contained current and sufficiently detailed information about potential risks to their safety and how these risks should be prevented or appropriately managed. Peoples risk assessment and management plans were being reviewed frequently and updated accordingly to reflect any changes in people’s needs.

Managers and staff had a clear understanding of the potential risks people might encounter and the actions required to prevent or safely manage them. Each person had a positive behaviour support plan in place, ensuring staff could access all relevant information and guidance to prevent incidents and respond appropriately when people became distressed.

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

The layout and interior decoration of the care home was ‘dementia friendly.’ For example, easy to read and understand large print and pictorial signage was clearly displayed throughout the care home. In addition, memory boxes containing family photos were located near people’s bedroom doors. All these visual cues helped people living with dementia orientate themselves and identify rooms that were important to them.

The premises were kept free of obstacles and hazards which enabled people to move safely around the care home.

There were effective arrangements in place to monitor the safety and upkeep of the premises. Regular checks were completed to help ensure the safety of the care home’s physical environment and fire safety equipment. Managers and staff told us they had clear guidelines available to help them deal with emergencies. In relation to fire safety, we saw emergency evacuation plans were in place to help staff evacuate people in an emergency. Staff confirmed they regularly participated in emergency evacuation drills of the premises

The provider made sure there were enough staff, who received effective support, supervision and development however, there were some gaps in staff training. They worked together well to provide safe care that met people’s individual needs.

Staff were supported to continually improve in their role. They received a mixture of e-learning and in-person practical and theoretical training and competency-based assessments. Staff told us they were receiving ongoing training that was always relevant to their roles. One staff member said, “The training is good here. There’s plenty of it and it always helps me become a better care worker.”

However, no staff had completed any Oliver McGowan training on learning disability and autism which is it mandatory for all staff working in adult social care to receive. Managers told us the provider was aware of this gap in staffs’ knowledge and skills and plans had already been agreed for all staff working in the care home to receive this mandatory training by 1st May 2026.

The provider employed enough permanent care staff and was not over reliant on temporary agency staff who may not be so familiar with people’s needs, preferences and daily routines. Staffing rotas were planned based on people’s dependency needs. Staffing levels matched the staff duty rota on the day of our unannounced site visit. Managers and care staff were visibly present throughout the service during the assessment and were quick to respond to people’s questions and requests for support. We heard 2 people request a hot drink which staff immediately made for them. A relative told us they felt more staff could be on duty in the home at busy periods of the day, but most people said the care home was adequately staffed. Comment included, “The staff work so hard here and I think sometimes they could do with more staff on duty to help out”, “There’s always plenty of staff around and they come as quickly as they can when you ask for any help” and “There’s always enough staff working whenever I visit the care home, which is quite often”.

Staff had ongoing opportunities to reflect on their working practices and to identify any further training, learning or support they might need. Staff had regular individual and group meetings with their line managers and fellow co-workers. One staff member told us, “We have regular meetings with our line managers and colleagues who are all supportive.”

The provider operated safe recruitment practices and only suitable staff were employed to work at the service.

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.

People lived in a clean, hygienic environment. Staff followed current best practice to reduce the risk of infections spreading. Staff were provided with relevant training to help them prevent and control the risk and spread of infection in the care home. They had access to resources and equipment to help them reduce infection risks and used this appropriately, which included adequate supplies of personal protective equipment (PPE). A person living in the care home commented, “It smells lovely every day and my room is kept nice and clean by staff.” A relative added, “The home is very clean and the staff work hard to keep it that way.” Staff maintain accurate and timely cleaning and food safety records, ensuring a clear and audible trail of actions taken to minimise infection risks within the service. The provider’s infection prevention, control, and food hygiene policies and procedures were current and reflected national guidance.

The provider made sure that medicines were safe and met people’s needs, capacities and preferences.

The service’s medicines systems were well-organised and safely managed. People's care records included clear, person-centred guidance for staff in relation to how peoples prescribed medicines should be administered in line with their individual needs and preferences. In addition, sufficiently detailed protocols were in place to guide staff in relation to the safe administration of peoples 'as required' medicines. Staff had also received up to date safe management of medicines training which was routinely refreshed. The provider had policies in place relating to the safe storage and administration of medicines. Staff were able to demonstrate how to correctly store controlled drugs as per the providers policy.

Medication stocks, balance and records demonstrated people consistently received their prescribed medicines safely.