Woodville House

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 66 (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 aimed to have a 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.

Systems were in place to ensure that when things went wrong, they were shared with staff so that they learnt from them. For example, the registered manager told us how medicine foil packs for 1 person had been cut up with intention of throwing away the empty parts, but this had resulted in some of the medicine being disposed of. There were lessons learnt and staff were supported so this did not do this again.

Staff told us how lessons were learnt from accidents and incidents and how they followed the providers procedures to make sure these were managed safely. One staff member said, “Whatever happens you have to do the form even if you find a resident on the floor and you don’t know what happened. But first you make sure the resident is not hurt and they are safe. The form goes to the manager who checks and makes changes, or it might be the resident needs to go to the hospital. You write it all down. If it happens and you’re not here, you learn in handover.”

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 service shared key details about people’s care needs including what medicines they were taking and family contacts with hospitals to ensure people received continuity of care and their needs were met. When people were discharged back to the home after a hospital stay, any changes were reviewed and recorded on the electronic care planning system.

The provider worked with people and healthcare partners to understand what being safe meant to them and how 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 with the staff that supported them. One person told us, “I like it here. I am safe. The staff are here.” People knew who to report their concerns to including the registered manager and felt confident these would be addressed.

Staff had completed safeguarding training and recognised the signs and symptoms of abuse. They knew it was their responsibility to report any concerns to their manager. One staff member told us, “Safeguarding is whereby we must ensure our residents are safe. They could be harmed by other residents, by family, or by strangers and even by staff. I hope that would never happen here. If we thought something was wrong, you tell the manager straightaway.”

Records were maintained of any safeguarding incidents. The registered manager was aware of the safeguarding referral process including reporting concerns to us and the local authority safeguarding team.

Systems ensured people were not deprived of their liberty. Where restrictions were placed on people’s care, Deprivation of Liberty Safeguards (DoLS) had been applied for and authorised by the local authority. This ensured any restrictions were managed safely and in people’s best interest. However, records had not been accurately maintained to show when the DoLS were due for renewal. The registered manager told us they would update the record so make this clearer.

The provider worked with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People and relatives told us staff involved them in decisions about people’s care. For example, a relative told us, “In the past if they’ve got any concerns they’ve got in touch with us, particularly when [name] was losing weight, they had a feeding plan and they were even encouraging snacks in between meals.”

Staff shared information about any changes needed to people’s care to ensure any risks were managed safely. For example, where 1 person found it difficult to swallow their food, discussions took place with them about changes needed to enable them to eat and drink safely so that choking risks were minimised. Arrangements were made for the person to be assessed by the speech and language team (SALT) and changes to the texture of their food was advised. Staff told us they worked with the person to ensure their food remained appetising to them.

Staff completed training to ensure they worked safely and could identify any risks when providing care. One staff member told us, “Training is valuable. Moving and handling is very common tool here so it’s good we learn how to do things safely. Like if a resident uses a ‘Zimmer’ frame, we know to put pressure on the frame, so it doesn’t tumble.”

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.

Overall, the provider detected and controlled potential risks in the care environment. A range of internal and external checks were completed to ensure equipment and facilities supported the delivery of safe care. However, these checks had not identified some of the shortfalls we found.

One person’s wardrobe was not fixed to the wall to prevent it from toppling over and causing them potential harm. Wardrobes in other rooms had been secured to the walls. A stair lift in 1 area of the home was not working and had been out of use for over a week. The broken stair lift had resulted in 1 person choosing to stay in their room because they did not feel safe using the stairs even with staff support. A risk assessment had not been completed to identify any risks associated with the stair lift not working. This meant it was unclear risks had been identified and mitigated to ensure people in this area of the home would remain safe particularly in the event of a fire or emergency.

A fire risk assessment was in place and appropriate fire safety checks had been completed. This included personal evacuation protection plans (PEEPs) for people showing how they would need to be supported in the event of a fire. We saw there was a PEEP in place for a person no longer at the home which meant this could be misleading to the fire service. This was removed during our visit. Staff knew what to do in the event of an emergency and told us, “You straightaway go to the front by the alarm box. The Marshall, either senior or manager send staff to the different area to check. You immediately report back and then get told what’s next. If it’s real, then the Marshall rings the emergency fire brigade.” We saw most of the staff had completed fire marshall training, however, duty rotas did not identify a senior member of staff or fire marshall was always on duty.

We saw there were window restrictors in place to keep people safe from falls from height and hot water temperatures were at a safe level to prevent any burns or scalds to people’s skin.

The provider told us they had assessed areas needing refurbishment and there were plans in place for this to be completed.

The provider aimed to make sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together to provide safe care that met people’s individual needs. However, staff were not always deployed effectively, as arrangements to cover housekeeping and catering duties were not consistently maintained without impacting the delivery of care.

One member of staff told us, “Staffing is a problem. The rota gets changed so it goes to 2 care staff in an afternoon sometimes. If there is no laundry or cook, we have to do that as well.” Another said, “We often work short like yesterday the cook rang in sick so 1 of the care staff had to do the cooking which left the floor short. There are at least 4 residents who need 2 staff.”

Staff told us they had completed an induction and training to support them in their role. One staff member told us, “I had good support for my induction. I learnt a lot. We must do training and the old owner made sure we knew when our training was due to keep it all up to date. I don’t know what will happen with the new owner, we haven’t been told yet.”

People and relatives were positive about the staff team and people felt their needs were usually met. A relative told us, “Every time we go in, they’re very attentive to all the residents.” However, 1 person’s experience was that sometimes staff took a long time to respond to their call bell. When we checked the call bell logs these had not been completed since 2025. This meant it was not possible to confirm if people were kept waiting for long periods of time for assistance.

Whilst staff were usually recruited safely, the provider’s recruitment procedures had not been followed consistently. For example, the provider had recruited 1 staff member without evidence they had completed the required training. They also had no reference from their last employer. This meant the provider could not fully demonstrate they had obtained all appropriate information to assure themselves the staff member was suitable to work with vulnerable people.

The provider did not always effectively 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.

The home was generally maintained in a clean condition and people told us their rooms were cleaned regularly. However, there were some areas where good practice was not always followed to maintain good infection prevention and control. For example, some wooden door frames, windowsills, handrails and skirting boards were paint chipped making them difficult to clean effectively. Some of the free-standing fans such as the fan in use in the kitchen had an excessive build-up of dust. Staff were observed carrying dirty laundry along hallway without the use of appropriate containers and food was being transported to people around the home without being covered. This meant practices to prevent the risk of spread of infection were not being effectively followed.

The provider told us of plans to improve the décor of the home including the replacement of some of the carpets where they had worn.

Staff told us they had personal protective equipment available to them. One staff member said, “Yes, we have gloves and aprons, and you learn why you need to wear them when you do your training.”

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.

People told us they received their medicines as prescribed although not all knew what their medicines were which meant this may not have been fully explained. Relatives told us staff provided them their family member’s medicines when they went out of the home on a visit. This was so they could administer them as required. One relative told us, “A few times we have had to be involved if [Name] has come out with us and if there’s something they need during that time (medicine) they have always given it to us.”

Staff responsible for the administration of medicine had completed relevant training and had their competency assessed each year or sooner if an issue of concern was identified. We saw medicines were stored disposed of safety and staff administered medicines in accordance with best practice.