Woodfield Care Home Limited

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 good. At this assessment the rating has changed to 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 and staffing.

This service scored 31 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate and report all safety events. Lessons were not learnt to continually identify and embed good practice. The registered manager shared with us a complaints log which showed 2 recorded complaints. However, we had received intelligence and feedback from people of a further 5 complaints. None of these were recorded or investigated and no outcomes had been recorded in line with the provider’s complaints policy. One of the complaints which was logged highlighted a 2-month delay in the recording and investigation of the complaint and no reasons were recorded for this delay. Nor was there any communication with the complainant to outline the reason for the delay. There was no learning recorded from this complaint. The second complaint was recorded, investigated and responded to by the registered manager in a timely way. However, the complainant expressed concerns around the investigation and outcomes, and a further investigation was being carried out into the complaint by senior management and remains ongoing.

The provider did not work well with people and healthcare partners to establish and maintain safe systems of care. A suspension on new admissions had been put in place by the local authority from 3 October 2025 due to concerns relating to governance oversight and lack of clinical lead at the service. Stakeholders had provided regular meetings, support and training to the provider and reported improvements were still required. During our assessment of the service, we identified breaches of regulations in relation to safe care and treatment, staffing and governance of the service consistent with concerns already highlighted and shared with the provider prior to our assessment.

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. They did not share concerns quickly and appropriately. We found incidents had taken place where care plan guidance had not been followed for 1 person who presented with distressed behaviour. For example, records did not show if staff had tried distraction techniques to calm the person before administering medication. There was no incident report or safeguarding referral for a person who had a wound which had resulted from an injury whilst been supported with movement and handling support from staff. The provider had a recently reviewed safeguarding policy and staff had all attended safeguarding training; staff told us they would be confident in reporting any safeguarding concerns.

The provider did not work well with people to understand and manage risks. They did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Two people’s care plans showed they required regular repositioning due to 1 person being at high risk of skin damage and the other person had an ungraded pressure ulcer. Records showed repositioning was not carried out in accordance with care plans or the advice given by healthcare professionals. We observed a senior staff member providing significant support and guidance to staff when moving and handling people. However, in the senior staff member’s absence, we observed unsafe moving and handling practice carried out by staff. An incident involving a person living at the service was reviewed by inspectors. On review of information the risks were known to the provider prior to the incident and no relevant risk mitigation was in place prior to the incident.

The provider did not always detect and control potential risks in the care environment. We found concerns with the security of the building. Incidents reported a vulnerable person living with dementia who lacked capacity had left the building unnoticed by staff on more than 1 occasion. Appropriate measures were not in place to ensure the security of the building and safety of vulnerable people.

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. The registered manager told us a dependency tool was used and completed monthly by the provider to establish required staffing levels for the service in accordance with people’s needs and we saw evidence of the dependency tool in use. Staff rotas we reviewed showed staffing levels were often below the those stated in the dependency tool and saw this during our site visit. We received mixed feedback from staff; some staff told us they felt staffing levels were sufficient and others spoke about recent improvements to staffing levels and we were also told by staff that staffing levels were not sufficient and more staff were required on shift. Staff inductions were reviewed and showed inconsistent inductions for new staff. Supervisions were not completed in accordance with the services policy. Some staff told us they received supervisions regularly and felt well supported whilst other staff told us they did not feel supported, and they did not receive regular supervisions. Staff had received mandatory training, and most staff told us they felt the training they received was sufficient to their role.

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. Following a recent outbreak at the service, intelligence from stakeholders informed us people who were suspected to have a potential infectious disease were not isolated and visitors were not informed until the outbreak was confirmed. Once the diagnosis and outbreak were confirmed this was reported appropriately by the provider. We observed staff did not following safe infection prevention and control procedures in relation to personal protective equipment. We observed cleaning tasks and the allocation of staff to maintain cleanliness and observed no concerns with cleanliness or odours in the building. The provider had an updated infection control policy.

The provider did not make sure that medicines and treatments were safe and met people’s needs. We found concerns with the safe storage, signing in, missing medication, checking stock, and returns to pharmacy. We found people were not receiving their medication as recommended. For example, when we checked guidance for ‘As and when required’ medicines, we found the medicine had been administered before the recommended 12-hour gap in between doses. We also found the stock number of medicines were recorded, but actual balances of medicines were incorrect. Some people required ‘as required’ medicines, but staff did not always have clear guidance on when these medicines were needed. They did not clearly record why they had provided these medicines. We observed sharps container and medicines boxed and bagged were not stored safely and were accessible to vulnerable people living with dementia. The provider had a recently reviewed medicines policy in place and staff had received medicines training. However, the availability of policies and training had not resulted in safe medicine management.