Date of assessment: 29 April – 17 June 2025. Woodhall care services limited is a domiciliary care agency. The service provides personal care to people in their own homes in the community. At the time of our assessment there were approximately 295 people using the service. Not everyone who used the service received personal care, the approximate number receiving personal care was 190. The service provides support to people with dementia, learning disabilities and/or autism, mental health conditions, physical disabilities, sensory impairments, services for everyone, eating disorders and substance misuse problems. We found a breach around consent to care. No mental capacity assessments were completed for people who needed them. The registered manager and nominated individual told us everyone using the service had capacity. Information in people’s care plans was contradictory, and we were not assured about some people’s capacity to make specific decisions. Where some people used bed rails, we found no recorded reasons, risk assessments or safety checks in place. The registered manager and nominated individual agreed to address this as a matter of urgency. Records for people’s care and support did not always show how care was delivered in a person-centred way, including time spent with people and end of life care. There were systems in place to ensure people received good quality care. People could raise concerns. Managers investigated incidents and complaints thoroughly. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular supervision to maintain high-quality care. Staff managed medicines well and involved people in planning changes.
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Woodhall Care Services Ltd received a Good rating overall following a focused inspection of Safe and Well-Led domains, improving from Requires Improvement at the last comprehensive inspection. The service demonstrated effective risk management, safe medicines practices, and strong leadership, with minor gaps in trend analysis of incidents and safeguarding escalation processes already being addressed.
Concerns (2)
moderateSafeguarding: “following a recent investigation, they have acknowledged lessons learnt and understand the need to escalate concerns.”
minorIncident learning: “analysing trends and patterns which could reduce risks required review. The registered manager and nominated individual took immediate action to address this.”
Strengths
· Risk assessments were individualised and regularly reviewed, covering medicine management, mobility and personal care.
· Staff deployment ensured punctuality and consistency, with staff living near service users organised to arrive on time.
· Medicines were managed safely with correct MAR records, regular audits, and trained medicines administration staff.
· Staff wore PPE appropriately and understood infection prevention and control measures.
· Provider demonstrated continuous learning by transitioning to an electronic care records system.
This targeted KLOE inspection of Woodhall Care Services Ltd found that sufficient improvements had been made to medication management and governance since the previous 'Requires improvement' rating, with the provider no longer in breach of Regulation 17. The overall service rating remains 'Requires improvement' as this targeted inspection did not assess all areas of the key questions.
Concerns (2)
minorMedication management: “some 'as required' medicine protocols were not detailed...not clearly stated in their care plans. The provider took immediate action at the time of inspection”
minorRecord keeping: “We highlighted it would be beneficial if all action taken as a result of audits was clearly recorded. This provides an audit trail and clearly demonstrates issues identified have been actioned.”
Strengths
· Significant improvements made to medicine management since last inspection; provider no longer in breach of Regulation 17.
· New electronic medication administration system (EMAR) introduced with clear, up-to-date medication profiles.
· New medication administration officer role created to provide real-time oversight of medicines.
· Daily and monthly medication audits effectively identified and addressed issues promptly.
· Staff felt supported by management and able to raise concerns; positive team culture reported.
Quality-Statement breakdown (2)
safe: Using medicines safelyNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsNot rated
Woodhall Care Services Ltd received an overall rating of Requires Improvement at its first inspection following relocation, with two regulatory breaches identified relating to medicines management (Regulation 12) and governance (Regulation 17). While staff were caring and well-trained and people felt safe, significant weaknesses in medicines documentation, care plan detail, and quality monitoring systems required remediation.
Concerns (9)
criticalMedication management: “The MAR stated D Box and did not list which medicines were to be administered. People did not have a medicines profile in place.”
criticalMedication management: “MARs did not always contain details of topical medicines and people's care records did not always contain enough information to advise staff of where and when topical creams should be applied.”
criticalGovernance: “Concerns we identified with medicines administration records should have been identified through a robust system of checks.”
moderateCare planning: “Care plans were not always person centred and did not contain information about people's preferences and how they wanted their care to be delivered.”
moderateCare planning: “One person's needs assessment stated they lived with epilepsy. There was no care plan or risk assessment to reduce the risks associated with this.”
moderateGovernance: “There were none in place for areas such as call logs, daily notes, service user surveys, complaints, accidents and incidents.”
moderateIncident learning: “More work was required to demonstrate that investigations were thorough and comprehensive and lessons learned were reflected on and communicated.”
moderateRecord keeping: “Staff had only recorded what food had been provided to the person but not what they had eaten. This meant that the person's risk of malnutrition was not being appropriately monitored.”
minorComplaints handling: “The service needed to improve documentation of actions taken, and whether people were satisfied with the outcome.”
Strengths
· Staff were kind, caring and treated people with dignity and respect, with consistently positive feedback from people using the service and relatives.
· Continuity of care was strong, with staff organised into geographic teams ensuring people saw familiar carers regularly.
· Safe recruitment procedures were followed including DBS checks and references for all staff reviewed.
· Staff received appropriate training including the Care Certificate, safeguarding, moving and handling, MCA, dementia and infection control.
· The service was compliant with the Mental Capacity Act 2005 and obtained consent before providing care.
Quality-Statement breakdown (18)
safe: Medicines managementRequires improvement
safe: Staffing levelsGood
safe: RecruitmentGood
safe: SafeguardingGood
safe: Risk assessmentRequires improvement
effective: Nutrition and hydration recordingRequires improvement
Woodhall Care Services Ltd retained an overall 'Requires Improvement' rating at this follow-up inspection, with a continued breach of Regulation 17 (Good Governance) due to medication administration records being incomplete, inconsistent and not effectively identified by internal audits. Strengths included compassionate, person-centred care delivery, reliable staffing, good partnership working and an improvement in the 'Responsive' key question from 'Requires Improvement' to 'Good'.
Concerns (5)
criticalMedication management: “Where people were administered medicines from a dosset box there was no breakdown of the individual medicines on the MAR sheet.”
criticalGovernance: “monthly medication audits were in place, but they had not been effective.”
moderateMedication management: “Protocols were not in place detailing when staff should offer 'as required' medicines. This did not support safe and consistent practise.”
moderateRecord keeping: “Hand written information on MARs was not always clear and legible.”
moderateGovernance: “we reviewed medication checks we identified gaps in signing and inconsistencies which had not been identified through audit”
Strengths
· People and relatives consistently praised staff as caring, respectful and trustworthy, with one person stating staff are 'trustworthy and respectful in every way'.
· Safe recruitment processes were followed and staffing levels were maintained with timely, consistent support from a well-established team.
· Care plans described personalised support, reflected individual choices and preferred routines, and were updated when needs changed.
· The registered manager promoted an open culture around accidents and incidents, with improvements to monitoring and lessons-learned recording.
· Staff received regular supervision, annual appraisal, spot checks and up-to-date mandatory training.
Quality-Statement breakdown (20)
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and management; learning lessons when things go wrongGood
safe: Preventing and controlling infectionGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff support: induction, training, skills and experience
effective: Healthcare professional liaison
Good
caring: Dignity and respectGood
caring: Continuity of care workersGood
caring: Person involvement in care planningGood
responsive: Person-centred care planningRequires improvement
well-led: Governance and quality assuranceRequires improvement
well-led: Leadership and management cultureGood
well-led: Staff engagement and meetingsGood
Good
effective: Staff working with other agencies; supporting people to live healthier livesGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and controlGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles; quality performance, risks and regulatory requirements; duty of candourRequires improvement
well-led: Promoting a positive culture; engaging and involving people and staffGood
well-led: Continuous learning and improving care; working in partnership with othersGood