Woodland 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 Inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to safe care and treatment and safeguarding.
 

This service scored 38 (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 or report safety events. Lessons were not learnt to continually identify and embed good practice.

People did not benefit from a service that learned from incidents and concerns. Repeated incidents involving distress and self-injurious behaviour continued to occur without evidence that support strategies had been changed to reduce the likelihood of recurrence.

Incidents were recorded and reviewed by senior staff. However, reviews were often generic and failed to analyse triggers, identify themes or demonstrate learning. Positive Behaviour Support reviews were not undertaken consistently, despite ongoing incidents. Debriefs took place but did not consistently lead to improvements in practice.
 

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People’s transition arrangements had historically been carefully planned. However, current systems for coordinating care and responding to healthcare concerns were less effective. Staff did not consistently involve healthcare professionals when people experienced repeated head injuries or a deterioration in their wellbeing.

Family visits and contact arrangements were generally supported effectively.
 

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, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

People were not protected from abuse and improper treatment. Multiple incidents involving injury and restrictive interventions had not resulted in appropriate safeguarding action being taken.

Staff understood safeguarding processes but did not consistently recognise safeguarding concerns in practice. We identified repeated incidents of self-injurious behaviour resulting in head injuries where medical advice had not been sought. Records concerning bruising and unexplained injuries lacked sufficient detail. Restrictive practices were not accurately recorded or monitored. We raised safeguarding concerns with the local authority during the assessment.

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 that appropriate DoLS applications had been made, and where there were delays in these being authorised by a supervisory body these were chased up by the management team. However, restrictions were not always reviewed or appropriate.
 

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

People were not protected from risks to their health, safety and wellbeing. Systems to identify, assess and manage risk were not effective. Incidents involving self-injurious behaviour, including repeated head injuries, were not consistently reviewed to ensure appropriate action was taken or lessons were learnt. Staff and leaders had become complacent, which resulted in opportunities to seek medical advice, safeguard people and improve support being missed, this put people at risk of harm.

People's risks were assessed but support often focused on managing behaviour rather than enabling choice, personal development and positive risk taking. Restricted access to facilities and ongoing, close supervision were not always supported by clear justification or progression plans.

Risk assessments were in place but did not always contain sufficient guidance and reviews following incidents were inconsistent. Risks relating to health conditions and self-injury were not fully considered, this put people at risk of harm.
 

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The environment did not consistently promote safety, comfort or wellbeing. The home required significant maintenance. One person’s relative told us, “The toilet near [Person’s name’s] bedroom has a fire device in there without a cover, and I could see wires hanging out.” During our visit to the service, we saw exposed wiring and damaged walls.

Some restrictions within the environment lacked evidence of review or authorisation. The environment appeared institutional and did not consistently consider people's sensory needs.

The provider acknowledged the findings of the assessment in relation to environmental safety. They began to implement the actions required to make improvements during the assessment. However, action had not been taken promptly enough, and this had negatively impacted people’s experiences of living in the home.
 

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.

A recruitment policy was in place which supported safe recruitment practice. However, not all staff files contained evidence the necessary recruitment checks had been carried out., For example, there were gaps in employment history for some staff that had not been explored.

The provider generally deployed sufficient staff and training records demonstrated staff had received suitable training for their role. However, observations showed staff frequently supervising rather than actively engaging with people. Daily records demonstrated limited access to meaningful activities despite staffing arrangements that should have supported greater participation in community life. Agency staff were regularly used despite plans identifying the importance of staff consistency.

One person’s relative told us, “The care staff don't seem to know much about [Person’s name], some have better knowledge than others and some responses I've seen from staff have been weak.”
 

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.

The home was generally clean. However, we identified concerns relating to food hygiene procedures, food probe monitoring, frozen food storage and management of opened food products. Fixtures and fittings were old, worn and in need of renewal.

The provider had not fully implemented effective processes to protect people from the risk of infection; this placed people at risk of harm.
 

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.

People’s medicines were not always stored safely. We identified concerns regarding medication room temperatures exceeding recommended limits on multiple occasions without evidence of appropriate mitigation or pharmaceutical advice.

People received their medicines as prescribed, and staff followed appropriate procedures for administration. Where people required medicines on an as required basis, we saw these were managed appropriately.