Woodhall 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.

This service is not scored or rated.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

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.

Incident reports were completed by staff after any incident involving a child and were reviewed by the manager to take appropriate action.

Leaders shared learning with staff in regular meetings. Staff were empowered to speak up if they had any concerns. The provider had daily meetings to ensure learning was shared with staff as soon as possible.

In minutes of meetings, we saw examples of learning from incidents. This included improvements made to the handover information given to staff who moved between services. This was in response to an incident where staff were unaware of an issue and had flagged this to management.

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.

We saw examples of effective communication by the registered manager with Social Workers regarding a child who needed extra support. The provider ensured that staff who moved between services were given an appropriate handover of the needs of the children in each home.

When a child’s next setting was identified there was careful and thorough transition planning to support a safe and co-ordinated transition. However, for some children record keeping did not adequately reflect that transition planning and arrangements had been discussed.

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.

We found that statutory notifications required had been sent through to the Care Quality Commission.

The provider was in regular contact with the multi-disciplinary team to help ensure that all safety concerns were addressed. One of the children we spoke with told us that they felt safe at Woodhall House.

Staff were trained in safeguarding and the provider had policies that were accessible to staff to refer to about safeguarding.

There was robust governance, oversight and reporting mechanisms. For example, the CAMHS specialist nurse, who had oversight of medicines management in the home, produced a monthly report that identified any safeguarding concerns.

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

Children were kept safe through comprehensive risk assessments that reflected their needs and were regularly updated. Children contributed to their risk assessments and were supported to understand the actions that kept them safe.

Risks were described in the risk assessments and care plans. Staff reported they have enough detailed information to manage risk and they understood the risks well.

Children’s needs were risk assessed to enable them to access the community and be safe. We saw that this involved providing extra staff to support the children if they were deemed required by the risk assessment.

Risk assessments carefully considered all aspects of the child’s presentation, and the least restrictive measures were in place to keep the child safe.

Staff had received extra training to deal with behaviour that communicates, restrictive practice and clinical risk.

Incident reports were signed by the staff member and reviewed by the manager for oversight. We saw that all notifications had been appropriately reported to CQC. Risk reviews were regularly updated.

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

We saw evidence that the provider had a programme of maintenance to maintain the safety of the environment. This was overseen by the Registered Manager who performed daily walks around the home and jobs were booked in by head office. We saw that areas that required attention, for example, bathroom tiles to be replaced, were already scheduled to be done. We were told that required actions from the fire risk assessment were overseen by the business manager and that these were booked in to be done.

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.

Safe recruitment (including DBS) was done by head office but there was oversight from the Registered Manager who interviews candidates and the Operations Manager to ensure that staff had the knowledge and skills to provide safe care to the children.

Staff received an induction and had two weeks to shadow another member of experienced staff. Staff then had regular supervision and reviews, including a probation review. Staff had a personal development plan.

We saw the staff training matrix and that staff were up to date with mandatory safeguarding training. One staff member was overdue a face-to-face safeguarding training update, but they had done the online safeguarding training. Staff were up to date with restraint training.

The Registered Manager was sent the profile and qualifications of any Agency staff prior to booking so they could ensure that they were qualified to meet the needs of the children. Agency staff were then inducted to the home and mentored by an extra staff member for the first two shifts. This was corroborated by an agency staff member on duty at the time of the assessment.

We saw evidence that staff supervision was done monthly or more frequently if required, we saw evidence of 2 weekly supervision when a staff member needed support. When training needs were identified, staff were supported by training from the mental health team, or external agencies if required. This included case presentations to ensure that all the needs of each child were explored.
The organisation did not routinely do exit interviews for staff who left the organisation, but all staff were offered this.

Multi-disciplinary team meetings, where each young person’s observation levels, risks and progress made were discussed were used to inform the Registered Manager of the staffing numbers and skill set required to manage the home safely.

The provider mostly had processes in place to assess and manage the risk of infection.

The provider had policies and procedures for managing infection control.
Audits were undertaken to monitor infection control, food hygiene, bedrooms and bathrooms and cleaning schedules and external cleaners did a deep clean every month in the home. The registered manager performed daily walkarounds, legionella checks, water temperature checks and health and safety audits.
All staff completed infection control training including managing self-harm, first aid and infectious illnesses.

However, we found that infection prevention and control measures in the medicines administration process were inconsistent during the assessment. This was regarding cleaning surfaces and sanitising hands prior to medicines administration.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Changes to children’s medical management was discussed and agreed by the multi-disciplinary team. Recommendations for monitoring was stated in the child’s care plan.

We saw evidence in the clinical records that the Consultant Psychiatrist undertook regular medication reviews based on increasing risk and increasing incidents of self-harm.

Medicines were ordered, stored and administered according to the policy, which had been recently updated.

We saw evidence that care staff undertook weekly medicines audits and the CAMHS specialist nurse completed a monthly audit which was shared within the organisation. This meant that any medication errors were highlighted, and lessons learned were shared widely.

The most recent audit identified an issue with some gaps in weekly audits which was highlighted to be addressed by the Registered Manager.

The accurate and timely recording of medicines administration was generally effective. However, it was noted that on one specific day medicines had not been counted or recorded in children’s MARS charts. This error had been identified, an incident report was completed, and leaders were taking action to address this and provide staff training/updates.

Controlled drugs administration required two signatures and regular medications required one staff signature and we saw evidence of this in the records.

Children had access to easy read explanations of how their medications worked and the possible side-effects.

The Consultant Psychiatrists were registered with the General Medical Council and prescribed within the scope of their registration, clinical experience and expertise. All medications prescribed were discussed with multi-disciplinary team including the child’s GP. The Psychiatrists had annual appraisals and were both in separate clinical peer supervision groups where guidance about prescribing and treatment was shared and discussed.