Woodhall Support Services Ltd

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 requires improvement.

The provider was in breach of the legal regulation relating to safeguarding service users from abuse and improper treatment.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 59 (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 or positive safety culture. Risk to people were not managed effectively.

Systems and practices did not always ensure people were protected from further risk following an accident or incident. We found incidents were not consistently recorded in enough detail to explain what had happened or whether other agencies had been contacted. For example, for an incident involving a medicine error, records did not show whether the prescriber had been informed to ensure the person’s wellbeing. Despite this, the registered manager had taken action to reduce the risk of a similar incident occurring again. We identified the inappropriate use of a safety strap on a harness. However, the record did not provide detailed information regarding the incident.

On discussion with the registered manager, they confirmed there were no audits in place to monitor accidents and incidents. As a result, trends or patterns were not identified.

We saw environmental risk assessments for people’s home were available. However, there were no personal emergency evacuation plans (PEEPs) in place, which was concerning given some people had reduced mobility. Since our site visit, the registered manager has provided evidence PEEPs have now been developed for each person.

For people who required mobility equipment, the registered manager did not have systems in place to ensure this equipment was regularly serviced to protect both service users and staff. Following our visit, the registered manager assured us a system has now been implemented to ensure equipment is routinely serviced and safe to use.

Staff had completed health and safety training, and risk assessments were in place to promote people’s independence while supporting their safety.

The provider worked with people and partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services.

People could be assured their assessed needs would be met. Individuals told us a needs assessment was completed before they began using the service. One person described how the local authority and the provider worked collaboratively when carrying out their assessment. Information gathered from these assessments was then used to develop both a care plan and a risk assessment.

People told us they were actively involved in developing their care plan and risk assessment, ensuring the support provided reflected their preferences.

One staff member told us they had access to care plans to enable them to understand people’s care and support requirements. The staff compliance manager explained for all new service users, they accompanied care staff during initial visits to ensure staff understood how to support the individual effectively.

The provider did not always act on potential safeguarding concerns to ensure the safety of people. The provider did not share concerns with relevant agencies to ensure appropriate action would be taken to safeguard people from further risk of harm.

We could not be assured appropriate action would be taken when there was a risk of potential abuse. We found a medicines error, concerns relating to possible financial irregularities and the ineffective use of a safety strap had not been reported to the local authority safeguarding team or to the Care Quality Commission.

Records confirmed the registered manager had taken action to address the concerns identified. However, we found the registered manager was not fully confident in their responsibilities regarding the reporting of potential safeguarding concerns to the relevant agencies. This lack of understanding increased the risk people may not be protected from further harm.

The registered manager told us staff had received safeguarding training, and a staff member confirmed this. Access to this training should ensure staff have the skills to recognise abuse and how to protect people from this. We spoke with a staff member who demonstrated a good understanding of different types of abuse and explained they would report any concerns to the registered manager. They were also aware of external agencies they could share concerns with.

All the people we spoke with told us they felt safe when receiving support from staff. One person said, “The staff are more like my friends than carers.” Another person commented, “The staff are very friendly and that makes me feel safe.”

The provider worked with people to understand and manage risks. However, not all element of people’s risks were covered to ensure their wellbeing.

We found where people had specific health conditions, such as dementia, there were no specific risk assessments in place to guide staff in understanding the person’s needs. In addition, for people who required support with oral health, there were no oral health care plans or risk assessments outlining how staff should provide this support safely and appropriately.

We observed risk assessments were in place for mobility, choking risks and environmental safety. People told us they were actively involved in managing their risks, and staff had access to these risk assessments. These assessments were reviewed and updated in response to people’s changing needs.

The registered manager told us staff had received training related to risk management, including moving and handling, hoist training and food hygiene. We saw evidence of this training within the staff training matrix.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always ensure staff recruitment practices were robust. Although, there were always enough qualified, skilled and experienced staff, who received effective support and development. They worked together well to provide care that met people’s individual needs.

At our previous inspection, we found some staff had started work before all safety checks had been completed. During this assessment, we found 1 out of 3 staff recruitment files did not explore gaps in employment history. This meant we could not be fully assured recruitment checks were robust, to ensure staff were safe and suitable to provide care and support.

One staff member told us before they began working for the provider, 2 references were obtained and a Disclosure and Barring Service (DBS) check was completed. The files we reviewed confirmed these checks had been undertaken.

Discussions with the registered manager and a staff member confirmed an induction was provided before staff began delivering care calls, and records evidenced this. One staff member said, “I had a three‑day induction in the office where I received training.”

People were assured there were sufficient staff to meet their needs. People we spoke with said they had not experienced any missed calls and staff usually arrived on time. People who required 2 staff members to support them confirmed 2 staff were always provided.

The provider assessed and managed the risk of infection. People could be assured they would be protected from the risk of avoidable infections.

People and their relatives told us staff always wore disposable aprons and gloves when providing personal care and support. A staff member told us they had access to supplies of personal protective equipment (PPE). This helped to avoid the risk of cross‑infection.

One staff member confirmed they had received infection prevention and control (IPC) training, and the records we reviewed evidenced completion of this training.

The provider had an infection, prevention and control policy in place to support staff in following safe and effective practices.

Where people required support with meals, the registered manager was able to provide evidence staff had completed food hygiene training.

Medicine management was not always robust to ensure the safe handling of medicines.

We could not be confident people’s prescribed medicines would always be managed safely. There were no written protocols in place for the safe administration of ‘when required’ (PRN) medicines. These are medicines prescribed to be taken only when needed. For example, pain relief. We found inconsistencies with a person’s prescribed medicines which differed to what was identified in their ‘My care and support plan’ and ‘My medication and care support plan.’ This could cause confusion when administering their medicines.

The registered manager told us staff had received medicines training. This was confirmed by 1 staff member and supported by the training records we reviewed. Competency assessments were also carried out routinely to ensure staff’s practices remained safe and up to date.