The Woodlarks Centre

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to good governance of the service. Improvements were not found at this assessment, 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 did not always have a clear, consistent shared vision which was promoted in the home. The home supported people of a wide age range and with diverse needs. The registered manager told us that one of the founding principles of the service was to provide ‘a home for all’. They told us they felt this made the home unique and promoted the principle that people could achieve their potential and breakdown barriers. Whilst this was evident for some people, we found the systems and routines of the service did not always promote these principles for others. For example, systems for planning people’s care did not always holistically review their quality of life, and people’s goals and aspirations were not always known. This meant for some people living at Woodlarks they did not consistently have the opportunities to live as ordinary life as possible. In addition, some of the daily routines within the home limited people’s opportunities such as the lack of planning around the support people received in the evening and how plans for people to go out and be involved in day-to-day activities were planned. Following the inspection, the provider sent information regarding how they planned to implement changes and enhance the direction and culture of the service.

In other areas we found there was a positive and enabling approach to people’s care and support. The management team spoke of the importance of demonstrating a caring approach to people’s support and we observed this was understood and practised by staff. For some people living at Woodlarks, the support they received had brought significant improvements to their lives through increasing their independence, mobility and social opportunities.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills and knowledge required to ensure people received a truly person-centred service as best practice guidance was not always known and embedded into practice. The management team were unaware of the Right Support, Right Care Right Culture guidance. This meant they had not ensured the support and planning had been reviewed in line with this. This impacted a number of people living at Woodlarks who were not always offered the opportunity to have their needs assessed holistically. In addition, whilst the management team found best interest decisions had been recorded by the previous registered manager, they were unaware of the MCA process and the importance of following the Mental Capacity Act to ensure people’s rights were protected.

In other areas we found the management team were skilled in their roles and understood people’s needs well. They treated people and staff with care which fostered an open approach where concerns could be discussed, and actions implemented. The management team clearly knew people well and staff felt they were able to ask for their support with any tasks within the home. One staff member told us, “We are part of a team, all of us together, part of a family.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt able to discuss any concerns with the management team and felt they would be listened to. One staff member told us, “They have helped me in so many ways. They are always there to listen and will help in whatever way they can.” We observed the management team spent time with people and knew them well. This helped to assure people and their relatives they were present and available to discuss any concerns.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us they felt valued and respected. One staff member told us, “We discussed this as a team. We won’t accept any discrimination, and we need to work together as a team to make sure of this.” The registered manager told us, “We have a multi-cultural workforce, and I see that as a really good thing. Because we have that diversity in the home we should take advantage of that. It gives residents the chance to see and understand different things.” Staff had completed equality and diversity training, and policies were in place for the management team and staff to refer to.

The provider did not always have effective systems in place to ensure robust oversight of the care and support people received. Following our last inspection a series of audits had been developed to monitor the quality of the service people received. Whilst this had led to improvements in some areas of the service, this had not identified shortfalls in a number of areas. For example, the provider had identified the electronic records system was not fit for purpose and had put a workaround in place whilst this was being addressed. However, audits had not identified some of the care plans and risk assessments staff had been told they should work from contained inaccurate and/or contradictory information. In addition, we found some records contained inappropriate references to people and the care they received. Following the inspection the provider informed us these concerns had been investigated and fully addressed. However, these concerns had not been identified through auditing processes in order for the management team to address the issues. In addition, we found systems to monitor staff training were not effective in ensuring staff had completed the training they required in relation to their roles.

Systems to ensure CQC were informed of notifiable events in line with the providers regulatory responsibilities were not always effective. We identified 3 incidents where notifications had not been submitted as required. Two of the incidents were known to the management team although checks had not been implemented to ensure notifications had been completed. A third incident had been incorrectly recorded directly to a person’s records with no incident form completed. As there had been no review of the persons records, this notifiable incident was not known to the management team. The provider ensured these notifications were forwarded to CQC when this was raised with them.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Partners told us the service made referrals appropriately and when information was requested this was provided in a timely manner. Where appropriate, staff attended appointments with people, so they were able to get information and guidance relating to people’s needs first hand and share this with the wider staff team.

The provider did not always focus on continuous learning, innovation and improvement across the organisation. They did not always encourage creative ways of delivering positive outcomes and quality of life for people. The provider’s action plan concentrated on concerns identified during our last inspection and we found positive progress had been made to address the issues found. However, the provider did not demonstrate plans for improvements in how the service could develop and how people living at The Woodlarks Centre could be fully involved in this process. The registered manager told us they had not had time to attend external registered manager workshops and events for a few months prior to our inspection although said they had intended to make this a priority going forward.

Following our inspection the provider forwarded an action plan in response to our feedback and the subsequent review of current guidance. This included a greater emphasis in involving people in the development of the service, implementing Right Support, Right Care Right Culture guidance, increasing communication systems and the way in which care plans and objectives were reviewed with individuals.