The Woodlarks Centre

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

Staff told us they understood their responsibilities in terms of protecting people from abuse and poor practice and knew how to recognise and report abuse, including escalating concerns outside the organisation if necessary. However, we identified instances where people were not always treated with dignity. There were enough staff on each shift to meet people’s needs and keep them safe. Staff worked effectively with healthcare professionals to manage any risks involved in people’s care. Staff monitored people’s health and responded appropriately if they became unwell, including seeking advice from healthcare professionals when necessary. Mental capacity assessments and best interests decision-making did not always follow the principles of the Mental Capacity Act 2005. Some people’s rights had been restricted inappropriately and disproportionately. This was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had not obtained all the necessary pre-employment information in respect of staff to ensure they were of good character.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People said they felt safe at the home and when staff provided their care. One person told us, “I have always felt safe.” Relatives were confident their family members were safe at the home and said staff were kind and caring. One relative said, “The staff are very caring, as though they are a family, and care deeply for the individual.” Another relative told us, “I am happy with it because [family member] is happy. He is well cared-for.” Whilst people and their relatives felt the service provided good quality care, we found examples where people had been supported in a restrictive way that did not support or uphold their human rights. For example, the ‘Positive Behaviour Support’ section of a person’s care records listed an ‘intervention’ staff could implement if the person became frustrated as, ‘Withdrawal of things I want e.g. watching NO TV.’ The same person’s care plan indicated the person’s behaviour should be monitored and rewards issued for ‘good’ behaviour, stating, ‘I have a behaviour chart on my bathroom door to monitor behaviour, I get rewarded weekly if my behaviour excels.’ The care plan also indicated the person should have access to the television and their tablet as ‘rewards’ for what were seen as positive behaviours, rather than as a right. Following our onsite assessment, the provider provided us with evidence that the approach staff took towards the person was to offer more positive reinforcement than restrictions from December 2023. This was as a result of an appointment with the local Positive Behaviour Support team. However, the care plan had not been updated to reflect this at the time of our assessment which left the person at risk of having their rights restricted by staff who were not aware of this update. The provider confirmed the care plan has since been updated.

Staff understood their responsibilities in relation to safeguarding and knew how to report any concerns they had. Staff told us their managers regularly asked them if they had any concerns about people’s safety or wellbeing. One member of staff said, “When we are working with colleagues, we need to report any abuse to our senior; that is our responsibility. At the end of every day, we have handover and they ask about any concerns, and we can tell them.”

Staff engaged with people in a friendly yet professional way and we had no concerns about the way in which staff supported people

The provider had a safeguarding policy and procedure, and staff attended safeguarding training in their induction. The provider had contributed to section 42 safeguarding enquiries when asked to do so by the local authority. Where mental capacity assessments had been carried out and decisions made in people’s best interests, these did not always follow the principles of the Mental Capacity Act 2005. For example, a mental capacity assessment for one person relating to medicines stated the person had been encouraged to be involved in the decision-making process and their wishes had been established. However, there was no evidence to support this statement as no information about the person’s wishes had been recorded. The same mental capacity assessment stated the person’s next-of-kin had been consulted about the decision, but there was no evidence of consultation with the person’s next-of-kin or recording of their input. Where decisions had been made in people’s best interests, there was insufficient evidence that the least restrictive options had been considered. For example, a decision had been made to install bedrails on one person’s bed. However there was no clear indication that other less restrictive options had been considered and ruled out for the person, such as a safety crash mat.

Relatives said staff monitored their family members’ health and responded appropriately if their family member became unwell. One relative told us, “When [family member] wasn’t well a few weeks back, he had a high temperature, they told me about it and what they were doing about it. They called 111 and took their advice. Their advice was to give him paracetamol and to call his doctor in the morning, which is what they did.” Another relative said the provider managed their family member’s dietary needs well to keep them safe. The relative told us, “[Family member] has to have gluten-free food, which they do. They are very particular about that. They have a nutritionist there; she is right on that.”

Staff told us they were trained in how to manage risks and to support people safely. Staff knew the risks involved in people’s care and said they had to be aware of these when supporting people. For example, one member of staff told us, “We have to follow the guidance when we are transferring [person] to the wheelchair.” Staff understood the importance of effective communication with people when providing care and support with, for example, moving and handling. One member of staff said, “We have to take the time to communicate with them.”

We observed that staff provided people’s care in a safe way, including when supporting people to mobilise and to eat and drink

Nationally recognised assessment tools were used to identify any risks to people, including in relation to eating and drinking, skin integrity, and failing to maintain adequate nutrition. Where risks were identified, guidance had been developed for staff about how to manage these risks.

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

People told us staff were available when they needed them and that staff responded promptly if they used their call bells. Relatives confirmed there were always enough staff on duty to meet people’s needs when they visited. One relative said, “There always seems to be plenty of staff. I think the staffing is really good.” People were supported by a consistent staff team, which meant staff knew people’s needs well. People told us they knew the staff who supported them and enjoyed their company. Relatives confirmed their family members received their care from consistent staff who engaged with people in a positive way. One relative said of staff, “I think they are delightful. They do their best to engage with [family member].”

Staff told us they had time to engage with people and get to know them because staffing levels were good. One member of staff said, “We have time to chat with the residents. I never feel rushed because we have enough staff.' Before our site visit, we had received information of concern about the service which was submitted anonymously. One of the concerns was that some staff did not speak English fluently enough to be able to communicate effectively with people. We discussed this concern with a care manager, who told us the provider had recognised some staff needed to improve their English language skills and, as a result, held weekly English classes for staff. The care manager also told us staff were able to access e-learning in their own language to ensure they understood the information being presented. Some of the staff we spoke with told us they attended the weekly English classes and that their language skills had improved as a result.

We observed that there were enough staff deployed to provide people’s care and support in a timely way. Staff had time to engage with people when not providing their care and communicated effectively with the people they supported.

The staff recruitment files we checked did not contain all the necessary pre-employment checks. For example, one member of staff’s file did not contain a Disclosure and Barring Service (DBS) certificate. DBS checks help employers make safer recruitment decisions and include a criminal record check. We were advised a DBS certificate had been obtained for the member of staff but this could not be located. Another member of staff had previously been employed by a home care agency in the UK, but there was no reference from the home care agency on file, only a reference from a volunteer position in the member of staff’s home country. A third member of staff’s application form stated they had 3 years’ experience of working in care, but provided no information regarding when or where. This information had not been requested, and no references from the member of staff’s employment in the care sector were provided.

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

People told us staff helped them take their medicines as prescribed. Relatives said staff made sure their family members received their medicines on time, and took appropriate action if errors occurred. One relative said, “They dispense [family member’s] medicines safely, although there was an incident a few weeks back where a new member of staff missed one pill. They followed that up and they are retraining him.”

The general manager (who was also the nominated individual for the service) told us only senior care workers administered medicines, and that they received relevant training and their competency was assessed before they carried out this task. The general manager said if errors occurred, the member of staff responsible was removed from the administration of medicines until they had been retrained and their competence reassessed. The general manager told us the provider planned to implement an electronic system to record the administration of medicines in the near future, which they envisaged would reduce the potential for medicines errors.

Medicines were not always managed safely. The multi-compartment compliance aid used to support people who chose to manage their own medicines involved secondary dispensing. Secondary dispensing occurs when medicines are taken out of their original packaging and placed into another container for dispensing later. This is not good practice as supplied medicines need to be labelled in line with legislation or the dose administered immediately.  Although staff were secondary dispensing to support the person to self-medicate, staff were unable to describe any policy, procedures or guidelines followed to ensure the risks involved with this were minimised. This included ensuring staff were assessed as being fully competent to dispense medication in this manner, and guidance for staff to follow should the amount of a medication prescribed change mid-cycle. Most liquid medicines including those with revised expiry dates once opened lacked either date opened or a revised expiry date. This meant staff could not be certain the medicine was still at its optimum efficiency and within date. Since our onsite assessment, the provider has provided us with assurances that this has now been rectified. We found the storage and recording of controlled drugs needed improvement. We shared this feedback with the provider at the end of our site visit. In response to this feedback, the provider took prompt action to improve the arrangements for the storage and recording of controlled drugs.