Woodcote Hall

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 requires improvement. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

This service scored 72 (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 had a proactive and 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.

The registered manager completed analysis of all incidents which occurred at the home to look at possible patterns, causes, or risks associated with the incidents. This included patterns in the time of day when incidents happened and where the incidents occurred. One person had experienced falls in their bedroom, so the registered manager ensured appropriate health care referrals had been made and safety equipment put in place. People’s risk assessments were reviewed and updated when incidents occurred. This helped to identify any additional support people may need to reduce the risk of the same incident happening in the future.

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’s care needs were assessed on admission to Woodcote Hall and formed the basis of their care plan. These care plans considered any risks which affected people’s safety and detailed how staff should support them to keep them safe. The person, where able, and their relatives also contributed to creating their plan of care. One family told us they had all felt involved in their family member’s admission process to the home and had no concerns.

One staff member told us prior to a person's admission to the home, information regarding their care needs was obtained from either the local authority or the hospital, depending on the source of referral. People’s care plans were completed within 48 hours of their arrival and were regularly reviewed and updated to reflect any changes in their needs. One staff member told us they had the time to read people’s care plans and any updates to them.

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 told us they felt safe living at Woodcote Hall and felt safe when staff supported them. One person told us, “I feel safe being here. I like my door kept closed when I’m in my room as it makes me feel more comfortable. Staff know this and always close my door for me.” One relative told us, “Even though[person]is in their room, I feel they are very safe and happy.”

The provider had effective systems and practices to make sure people were protected from abuse and neglect. The registered manager ensured safeguarding concerns were reported promptly to the local safeguarding authority. Staff had received training in and understood what abuse was, how to identify it and who to report their concerns to.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found where restrictions were necessary to enhance people’s safety, best interest decisions had been completed, and DoLS referrals had been authorised. These were monitored and kept under review to ensure they were necessary and proportionate. People, and their representatives, were involved in the DoLS process. Staff understood DoLS and how this was used in the best interest of people to help keep them safe.

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.

The risks to people were identified and managed by individual risk assessments. These risk assessments, along with care plans, provided staff with clear guidance on how to help reduce the risk and keep people safe. Staff understood risks and how to support people safely. We saw staff supported people safely with their mobility and ensured, where needed, they used their walking aids. Staff used technology, including sensor mats and personal alarm pendants, to receive alerts when people may have been at risk or needed assistance.

Since our previous inspection, the provider had invested in the home’s environment to ensure equipment, facilities and technology supported the delivery of safe care. Risks associated with the premises and equipment were managed through a programme of safety checks and maintenance at the home. This included areas such as fire safety, ensuring equipment was in good working order and that all utilities were serviced and safe.

People lived in a safe environment which had been improved to meet their needs. Corridors had handrails, and bathrooms and toilets were adapted for people with mobility problems. People were encouraged to personalise their own rooms. The area manager had implemented a Dementia Strategy for 2025to2028. This was based on and used the King’s Fund environmental assessment to help develop a more supportive environment for people with Dementia. The area manager told us they are continuing to work on updating and improving the environment, so Woodcote Hall was a safe and comfortable dementia friendly home.

People had an individual personal emergency evacuation plan (PEEP), which recorded the level of support they would need to leave the building in an emergency. The provider also had a business continuity plan to ensure people would continue to receive their care in the event of an emergency at the home, such as a fire or failure of utilities.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We saw there were sufficient staff to promptly and safely support people when they needed it. People told us they did not have to wait when they needed support. One person told us they sometimes had to wait to get support with a wash in the morning after their breakfast but did not mind as they were happy to stay in bed and understood staff were helping other people. However, they did tell us if they used their call bell staff would come quickly. Everyone we spoke with told us staff came quickly when they used their call bells and pendants.

Staff worked together well to provide care that met people’s individual needs. One staff member said, “We are a good team and have enough staff now.”

Staff had received training relevant to their role and to help them support the needs of people. Staff understood the benefits of their training and 1 staff member said, “It helps me look after everyone, it makes it easier for me to understand them and why they may do something in a particular way.” New staff were supported by more experienced members of the team to help them during their induction to their role. This helped to ensure knowledge, skills and the home’s values were shared.

The provider’s recruitment procedures were safe. Pre-employment checks were carried out on new staff, including verification of references, right to work and enhanced Disclosure and Barring Service (DBS) checks. This helped to ensure only suitable staff were employed.

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.

People and their relatives told us staff kept the home clean and hygienic. One relative said, “The home and[person’s name]room is always kept clean, no complaints there.”

The provider's cleaning arrangements at the home helped to keep people protected from the risk of infection. Good practice made sure the environment, including people's rooms, were clean and hygienic. There were handwashing facilities throughout the building and access to hand sanitiser. Staff had attended training in infection prevention and control (IPC)although some were yet to complete this. Staff understood how to protect people from the risk of infection and when they were required to wear personal protective equipment (PPE).Housekeeping staff ensured equipment and substances were stored safely and all staff were seen using PPE in the right way as required.

We found no stock of one person’s medicine which they took only when required. This medicine had been incorrectly put into the medicine returns box. The registered manager told us this will be addressed with staff as a lesson learnt exercise. This is a concern as staff did not know this medicine was not in stock and could have had an impact if the person had required this.

One person had several missed doses of medicines due to them being asleep. Although this was a pattern, staff had not taken any action to seek GP advice to see if a different time of day could improve compliance. Another person ran out of their medicine, and it was not administered for 4 days. Staff had sent an email to the pharmacy to chase this medicine, but this was not sent until 3 days later. We found no impact on people, although this was a concern staff had not sought advice previously. The GP was contacted by staff when we brought these concerns to their attention. Following our inspection visits, the registered manager confirmed they had clarified expectations with senior staff regarding monitoring medicine administration and stock, and reporting concerns. They had also reviewed all actions taken and identified and discussed lessons learnt with senior staff.

Some people had their medicines ‘as required’ rather than being given at specific times. We identified discrepancies between some of the paper and electronic protocols. One person was prescribed a pain medicine which was given in a liquid form, however their paper protocol stated this was in tablet form. We found no impact on people because of this. Staff addressed this promptly and started to update the paper protocols during our inspection.

The provider used artificial intelligence (AI) technology to establish the pain levels of people unable to express their own pain levels. This supported staff to better manage pain for those whose ability to communicate fluctuated and to administer pain medicine as required.