Woodside Lodge

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent.

The service was previously in breach of the regulation in relation to good governance. Although we found improvements, some shortfalls remained, and the provider remained in breach of this regulation.

This service scored 61 (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 had a shared vision and values, detailed in their statement of purpose. The provider demonstrated a clear passion to improve the service, and had invested in multiple different resources to achieve this. Meeting minutes showed direction and culture were regularly discussed.

The provider had leaders at all levels who mostly understood the context in which they delivered care, treatment and support. Leaders mostly demonstrated the skills and knowledge to lead effectively. Although leaders were responsive when concerns were identified and shared, systems and processes still needed to be embedded to ensure concerns would be identified independently. People and their relatives shared positive feedback about leaders.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People and relatives were familiar with management and knew who they could speak to if they had a concern. They told us they were confident concerns would be acted on. People, relatives and staff had a variety of different methods to enable them to speak up and feed back to management. For example, through surveys and regular meetings.

The provider valued diversity in their workforce and worked towards a fair culture. We saw evidence of reasonable adjustments being discussed in staff supervisions, and staff team culture and morale was also discussed at staff meetings.

The provider had not yet embedded robust systems and processes to consistently, effectively assess, monitor and improve quality and safety. Although we found significant improvements since the last inspection, we also found some areas of concern had not been addressed in a timely manner. For example, although there were plans to make the garden secure, there were still no secure outside spaces that people could freely access without support, and consent was not always sought by those with the legal authority to do so. These were both identified as concerns at our last inspection. The provider did not always identify shortfalls independently and improvements still needed time to embed. Some shortfalls identified at our last inspection continued to be identified in external audits had still not been addressed in a timely manner. For example, gaps in care records were not always identified or acted on. Governance systems around the need for consent, medicines, recording and activities were not yet effective or fully embedded. This meant there continued to be exposure to the risk of harm for people.

The provider understood their duty to collaborate and work in partnership. They shared information with partners to ensure continuity in people’s care.

The provider focused on continuous learning and improvement across the organisation and local system. Leaders took prompt action in response to feedback shared by the inspection team, and were open and engaged throughout the inspection process. They continued to work with external consultants to make and embed improvements. However, we could not yet be assured shortfalls would be identified independently as improvements still needed time to embed and be maintained.