Date of assessment: 28 November 2025, 14, 15 and 16 January 2026. Woodhall Support Services Ltd is a domiciliary care service that provides care and support to people living in their own home. During this assessment, we reviewed the quality statements Safe and Well-Led. We found the registered provider was in breach of 2 regulations relating to safeguarding service users from abuse and improper treatment and good governance. Discussions with the registered manager, alongside a review of records, confirmed potential safeguarding concerns had not been referred to the appropriate agencies to ensure people’s safety. Care records did not contain the necessary information to support staff understanding about how to provide appropriate care. For example, dementia and oral care plans were not in place. Personal Emergency Evacuation Plans (PEEPs) were missing, which meant there was no clear guidance to ensure safe evacuation in the event of an emergency. In addition, for medicines prescribed as Pro Re Nata (PRN), there were no protocols in place to support the safe and consistent administration of these medicines. A review of the provider’s governance arrangements was required to ensure effective oversight of the service and to address the shortfalls identified during this assessment. Risk assessments were in place to promote people’s independence whilst ensuring their safety. Incidents had not been referred to the appropriate agencies. Action had been taken by the registered manager to reduce the risk of further recurrence. At the time of our assessment, the service was providing care to people with a learning disability and autistic people. However, the registered provider was not registered for this service user band. Although, staff had received training within this area. We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed autistic people and people with a learning disability respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. Since the site visit, we have received an application to add the service user band for learning disability and autism and an updated Statement of Purpose.
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Woodhall Support Services received an overall Good rating at its first inspection, with strengths in personalised care planning, medication management, staff training, and safeguarding. The Requires Improvement rating for well-led reflects the provider's failure to consistently apply recruitment procedures, with pre-employment checks not completed before two staff members commenced work, though immediate remedial action was taken during the inspection.
Concerns (2)
moderateGovernance: “A full employment history, references and criminal record checks had been requested but had not been fully obtained before some staff commenced working with people.”
moderateStaffing levels: “We identified two recruitment files where the necessary checks had not been completed prior to the staff members starting work.”
Strengths
· People felt safe with staff and risks were thoroughly assessed including adverse weather conditions and lone working
· Medication administration records were completed in full and staff were assessed as competent before administering medicines
· Holistic care plans were personalised to individual needs and regularly reviewed with staff input
· Staff received comprehensive training and shadowing opportunities, with positive feedback about management support
· Complaints were clearly logged, investigated and outcomes shared with people
Quality-Statement breakdown (26)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentRequires improvement
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Supporting people to live healthier lives, access healthcare services and supportGood
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 control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Supporting people to develop and maintain relationships to avoid social isolationGood
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, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staffGood
well-led: Continuous learning and improving careGood