Woodway 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. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

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.

The provider was in breach of legal regulation in relation to safe care and treatment.

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 always have a proactive and positive culture of safety. Staff listened to concerns about safety and investigated and reported safety events, however lessons were not always learnt to continually identify and embed good practice.

The provider told us they had no accidents or incidents. However, where events had occurred such as people becoming distressed these were not always reviewed to consider whether staff responses had been effective. The processes in place did not always provide enough detail to explore what may have contributed to these situations or to identify any recurring themes. This meant the provider could not always be assured that risks were being recognised or reduced, which created the potential for people to receive inconsistent support.

People told us staff acted quickly if a fall occurred. One person said, “I’ve had two or three falls and everybody comes more or less straight away to help. One of the carers came and fetched the senior and they helped me.”

The registered manager told us, “Whenever someone has a fall, we look at what we can do to prevent that fall.” They gave an example of a person who had fallen in the dining area. Staff responded promptly, reviewed the environment and rearranged the furniture to create more space. The manager reported the person had not experienced any further falls since.

Falls were investigated, and actions were taken such as reviewing equipment in use and identifying themes and trends to reduce the risk of reoccurrence.

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.

People and their families were supported to make informed decisions before moving in. They were encouraged to visit the home, meet staff, join activities and share meals to become familiar with the environment. People and relatives said they were involved in planning care and felt well supported during the transition. One relative told us, “We had three visits. I came first, then brought [family member]. We had lunch here twice.”

The registered manager told us they carried out thorough assessments to ensure new admissions were a good fit for the home and the existing group of people living there. They reviewed information from the local authority or hospital and met people in person to gain a full understanding of their needs. The manager said it was important not to disrupt the homely environment and to make sure new residents would integrate well.

One healthcare professional told us when people moved into the service from other settings, staff reviewed the discharge information thoroughly and proactively followed up on any required actions, including seeking support or clarification on medical changes.

People had emergency grab sheets in place, which accompanied them if they required hospital care. These included key information such as communication needs, health conditions, mobility requirements and relevant medical details, ensuring external professionals had an accurate summary of the person’s needs.

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 and their relatives told us they felt safe living at the service. One relative said they felt confident their family member was safe because “Staff are always checking on [Family member]. I hear them.”

Staff had completed safeguarding training and demonstrated a clear understanding of their responsibilities to protect people from harm.

Where people had restrictions in place as part of their care, these were recorded in their care plans and appropriate applications had been submitted to the authorising body for Deprivation of Liberty Safeguards (DoLS). The provider made referrals where people were potentially being deprived of their liberty. Where conditions were attached to authorisations, we saw these had been acted on and followed up.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We found improvements were required in how risks were documented and monitored. Some people communicated their needs through their emotions. One person’s care records did not clearly outline how staff should support people if they became distressed or what may cause them to become distressed. When people became distressed, staff had not always recorded the actions they took, and records were not reviewed to identify potential triggers or patterns. However, some staff were able to describe the strategies they used in practice, which helped to mitigate some of these gaps.

Some people were living with diabetes; however, their care records did not always include information about their usual blood sugar ranges. The registered manager described what the expected blood sugar ranges were for individuals and said care records would be updated to include individualised blood sugar ranges and clearer instructions for staff. This information is essential to help staff identify deterioration promptly and reduce the risk of avoidable harm.

People and relatives, we spoke with did not raise any concerns about the management of their health needs.

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.

Improvements were needed to ensure environmental risks were consistently identified and addressed. During our observations, some people’s call bells had been placed out of reach, and some communal toilets had non‑functional, outdated call‑bell systems. This meant people could not alert staff if they required urgent assistance, increasing the risk of harm due to delays in staff responding. We also saw two call bells hung on a communal banister. Although the registered manager told us these individuals were checked on regularly, placing call bells in walkways created avoidable trip hazards. By the second day of the inspection, call bells had been returned to people’s rooms. The registered manager also informed us call bells were now in place in the communal bathrooms as a result of the inspection feedback.

We found some free‑standing wardrobes were not secured to the wall, posing a risk of injury if they toppled. Following our feedback, the provider ensured these wardrobes were secured by the second day of the inspection.

Although staff carried out fire drills, the time taken to complete them was not always recorded. This limited the provider’s ability to identify delays, assess staffing levels during an evacuation and ensure procedures were effective.

Parts of the home required refurbishment. For example, one communal lounge and several bedrooms had chipped paint or wallpaper, with visible marks on walls and skirting boards.

The home had placed a sensor mat directly in front of a fire exit, which posed a risk in the event of an emergency as it could impede a safe and timely evacuation. In addition, a set of stairs had been restricted using a retractable belt to prevent people from accessing the area. The registered manager told us there was no one currently living at the service who would attempt to use the stairs. However, this had not been supported by a risk assessment, and the measure in place was not fully robust. The manager confirmed this would be incorporated into the environmental risk assessment and reviewed regularly to ensure it remained appropriate if people’s needs changed.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff had not completed all required training, including training to support people with individual health conditions which meant they did not always have the skills and knowledge needed to safely meet people’s specific needs. The registered manager told us that training relating to people’s individual health conditions would be arranged for staff to complete.

Staff told us they felt supported in their roles. Processes were in place to provide staff with one‑to‑one supervision sessions, annual appraisals and regular team meetings.

During the inspection we did not observe any delays in care. Staffing rotas reviewed alongside our observations showed there were sufficient staff on duty to meet people’s needs.

Recruitment processes were not always robust. One staff file showed unexplored gaps in employment that had not been followed up. This meant the provider could not be assured the person’s employment history was fully understood or that they met the required standards for safe recruitment. The registered manager told us they would address this and ensure the necessary checks were completed.

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.

We observed positive infection prevention and control practices. Handwashing signage was displayed in communal bathroom areas and all bins were foot‑operated, reducing the risk of cross‑contamination. Clinical and domestic waste was disposed of appropriately and bins were emptied regularly. PPE stations were available throughout the home, and staff were seen to use the correct PPE at the required times. Housekeeping staff had suitable products to ensure people’s bedrooms and high‑touch surfaces were cleaned regularly. Staff had also completed infection control training.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

There were shortfalls in the safe management of medicines. Some people received their medicines covertly, but there was no guidance in place to explain how this should be done safely. Staff told us medicines were being added to drinks, but this is not always appropriate as some medicines can change in effectiveness, taste or safety when mixed with certain fluids. There was also no confirmation from a relevant professional that this was the correct method of administration. Following our feedback, the registered manager sought advice from the health professional and obtained clear instructions for staff to follow.

Staff were not recording how much of a prescribed nutritional supplement one person consumed, limiting the ability to monitor whether their nutritional needs were being met.

Some medicines had been handwritten onto MARs without the required second staff check to confirm accuracy. PRN protocols were not always complete or consistent; in some cases, the information on the protocol did not match the handwritten MAR, and one person did not have a PRN protocol for a prescribed medicine. In another example, guidance was missing, although staff told us the person was able to explain their needs.

Topical medicine records were not always clear. Body maps did not consistently show where creams should be applied. However, staff we spoke with were able to explain where creams should be used.

Some people were prescribed pain patches. Staff were not recording the site of application. This is important because rotating patch sites helps reduce the risk of skin irritation. Staff we spoke with confirmed patches were being rotated appropriately, and the registered manager told us this was a recording issue that would be addressed.

For people prescribed time‑sensitive medicines, staff were not consistently recording administration times. Some medicines requiring a specific interval before meals did not always include this information. Staff we spoke with understood these requirements and told us medicines were being given at the correct times, but this was not consistently reflected in the records. The registered manager told us this was a recording issue that would be addressed.

Medication audits completed by the registered manager had not identified the shortfalls we found, meaning opportunities to address these risks had been missed. However, the registered manager assured us these records and protocols would be reviewed and updated.