Woodlands Health 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

We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as Good. At this assessment, the rating has remained the same.

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 service did not always have an appropriate system in place to allow a proactive and positive culture of safety based on openness and honesty.

We reviewed 3 significant events and found 2 did not demonstrate what actions had been taken to prevent reoccurrence. For example, we reviewed an incident where a person had been given a medicine incorrectly. The service was unable to demonstrate what actions had been identified following the incident, or that any learning was shared. The service had not followed their own policies and procedures in respect to significant events. Feedback from staff was mixed regarding whether they felt able to raise concerns and if they felt they would be responded to appropriately.

The service 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.

There were systems in place for processing information relating to new people who were joining the service. Referrals and test results were managed in a timely way, when we looked at tasks for the administration staff they had all been actioned.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

The practice could clearly explain their safeguarding process.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff could recognise a deteriorating person and knew of action to take. For example, sepsis training had been completed by staff, and most members of staff had completed basic life support training. Aide memoirs were available for reception staff to help identify emergencies. In November 2025, staff took part in a practical exercise to simulate an emergency to enable preparedness if a real-life incident was to occur. People were advised on risks related to their condition and actions to take if their condition deteriorated. All appointment requests were triaged by a team that was managed by a duty doctor who determined the most appropriate type of action. For example, booking an appointment or sign posting to alternative services.

However, we found some equipment was missing from the emergency trolley such as disposable aprons, eye protection, stethoscope, absorbent towel, and an adult pulse oximeter. After discussing this with the service, this was rectified before the end of the assessment.

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

There was a business continuity plan in place which was monitored and reviewed. An external company had conducted a fire risk assessment of the service in April 2025. The risk assessment identified that fire drills were carried out annually, however we did not see evidence of this during the assessment. We saw the service carried out weekly fire alarm checks. The service conducted legionella testing, and the results were acted on in a timely manner.

Contracts were in place to ensure the premises were maintained. The service conducted a monthly health and safety risk assessment; risks were identified and addressed.

Carpets were present in some of the consulting rooms; the service identified they were cleaned regularly on the health and safety risk assessment. However, no risk assessment for having carpets in clinical areas was evidenced during assessment.

The service 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.

Safe recruitment processes were not consistently followed. The service had appointed staff without adequate interviews and checks taking place. We looked at 5 recruitment files; 3 did not have references, and 2 did not contain a full employment history. A further member of staff did not have a current Disclosure and Barring Service (DBS) check completed prior to starting at the service. (A DBS check provides information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.)

The service had not ensured clinical staff received effective support and supervision. We saw prescribing practices for clinical practitioners were reviewed quarterly to ensure they remained within clinicians agreed scope of competence. However, clinicians’ consultation notes were not reviewed as part of this process to ensure outcomes were appropriate and prescribing was in line with best practice for the symptoms presented. Although a supervision policy was in place, there was limited evidence to demonstrate how the service assured the ongoing competence of its clinical staff. We did not see evidence this was supported by formal clinical supervision.

After the assessment, the provider told us they had introduced monthly clinical supervision sessions, which included case-based discussions and a review of prescribing practices.

There were a range of clinical and non-clinical roles in the service. Mandatory training was up to date and clinical staff had maintained their professional revalidation.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

The consultation rooms we viewed were carpeted, and there was no risk assessment in place to address the associated infection prevention and control risks. We raised this with the service who advised us that discussions regarding building upgrades are to occur in 2026.

However, the service had a designated infection, prevention and control lead and all staff had had relevant training. Risk assessments and audits were completed internally, and actions taken to mitigate risks, the last one being December 2025. We saw that cleaning schedules and Control of Substances Hazardous to Health (COSHH) risk assessments were maintained. Cleaning schedules were in place and followed.

Staff had access to gloves, aprons and masks and clinical staff used single use items and had access to body fluid spillage kits to mitigate the risk of infection to people. There was a clinical room audit undertaken in June 2025 by internal staff, they had an action plan with achievable timeframes to address the concerns identified and evidence showed that these risks had been acted on.

The service was clean and tidy and immunisation history for staff was seen in recruitment files.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Our remote clinical searches conducted on 11 December 2025 showed improvements were required regarding medicine reviews and the monitoring of some high-risk medicines.

The service had not conducted medicine reviews in line with best practice guidance. We reviewed 5 medicine reviews and found 4 did not contain necessary information to support continued prescribing. For example, we found these records had been coded as having received a medicine review, however there was limited or no evidence to show what had been considered as part of the review, such as whether all required monitoring had been checked before prescribing further medicine.

We identified 228 out of 1694 people prescribed a medicine used to treat heart failure or hypertension may not have received the required monitoring. We reviewed the records of 5 people and found 4 had not been monitored in line with national guidance. For example, they had not received a recent blood test to check their kidney function prior to a prescription being issued.

We reviewed one Medicine and Healthcare products Regulatory Agency alert (MHRA - providing alerts, recalls and safety information on medicines and medical devices) relating to a medicine used to treat type 2 diabetes. We identified 197 people who had been prescribed this medicine. We reviewed 5 records and found 4 people had not had the required monitoring. We also found all 5 people had not been informed of the associated risks as outlined in the MHRA alert.

We identified 91 people who had been prescribed a medicine used to prevent the loss of bone density for more than five years. We reviewed the records of 5 people and found there was no evidence of recorded reviews to confirm that ongoing treatment remained clinically justified.

We identified 62 people with hypothyroidism who had not received necessary monitoring in the last 18 months. We reviewed a sample of 5 records; we found all 5 were overdue monitoring tests. Following assessment, the service told us they had contacted all people identified and that the search would be repeated to ensure ongoing monitoring.

Following the assessment, we received assurances the service had acted on the areas of concern raised. The service told us they had reviewed all individual cases highlighted as potentially at risk, they stated each person’s record has been reviewed by a GP, and the appropriate action has been taken where required. We were told these included clinical reviews, person contact, arranging or chasing investigations, adjusting prescriptions, and documenting clear follow-up plans. The service reported they were satisfied there are no outstanding unmanaged risks relating to the specific patients identified. They told us they had reflected on the themes identified and strengthened their overarching systems and processes.

Patient group directions (PGDs), a legal framework that allows some registered health professionals to supply and/or administer specified medicines to a pre-defined group of people, without them having to see a prescriber (such as a doctor or nurse prescriber) were not always authorised in line with national guidance. For example, names were added to the record after the directive had been authorised by the GP and unused rows were not scored through.

After the assessment the provider told us they had implemented changes in response to our feedback. For example, a new monitoring and recall system to identify patients requiring follow up tests, they developed a MHRA policy and checklist for the management of alerts and they reviewed and updated all PGD’s.

The service did not hold all emergency medicines in line with guidance and they had not risk assessed the impact of this. During the assessment, the service ordered one of the missing medicines which was due to arrive the following day. Following assessment, the service sent us risk assessments for the remaining medicines that they chose not to stock.

The service was unable to demonstrate how frequently stock levels and expiry date checks were carried out as records had not been dated. Staff told us checks were performed weekly.

However, staff managed prescription stationery appropriately and securely. Medicines were stored securely and at appropriate temperatures. Waste medicines were recorded and disposed of appropriately including medicines returned by people. Staff stored medical gases, such as oxygen safely.