Woodlands Care Home

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 the last inspection we rated this key question requires improvement. At this inspection the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. 

This service scored 79 (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, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The registered manager promoted the values of the home by acting as a role model; embedding actions and behaviours into staffs’ daily practice including dignity and respect for each person, compassion and person-centred care in every interaction with people, relatives and staff. The values were displayed in the reception of the home; these were identified as being humility, accountability, achievement, passion and integrity. Regional manager audits included asking staff about their understanding of the values of the home and company.

Throughout the inspection, the registered manager demonstrated calm and professional behaviour and referred to the values during shift handover meetings and staff meetings. The registered manager carried out observations of staff practice to ensure they were providing care in a way which reflected the values of the home and highlighted examples of good practice, whilst addressing any behaviours which did not reflect the values.

Information on how to raise concerns was clearly posted around the home in different places. Staff felt there was a culture of collaboration, where people and staff were listened to and communicated with. A relative told us, “Good standards in a home are led from above. I think the manager leads a good team. We have had the odd problem since [person] came here but it has always been dealt with promptly.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders were suitably experienced and qualified and had clearly defined roles and accountabilities. Leaders had worked previously in the social care sector and had the skills and competence to get involved in the direct delivery of care if required.

The registered manager worked hard to ensure everyone felt part of the team by creating a positive inclusive culture, where every job role was valued, with open and respectful communication. The registered manager demonstrated to staff they were approachable by having an open-door policy; the deputy manager also provided support, and both were willing to help with any task.

The provider ensured there was always suitable managerial cover; this included leaders being available to provide advice to staff throughout the night and at weekends. Staff told us they felt supported and received the necessary support and supervision. A staff delegation chart was posted on each unit, identifying the duties they were responsible for each day.

There was an employee of the month initiative in place; the staff team voted for the employee and the identified team member received a gift voucher, and a certificate was displayed in the reception area; the news was also posted on the providers’ Facebook page.

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

Staff told us the felt able to raise concerns and that they would be listened to. There were mechanisms in place for staff to speak up and a culture in place to encourage them to do so. Effective communication was in place through team meetings, daily shift handover meetings, and formal individual supervision sessions to ensure staff had regular opportunities to engage with leaders. This was also supported by policies and information supporting staff to raise concerns externally if required.

People and relatives felt their voice was heard. The provider had an up-to-date freedom to speak up and whistleblowing policy. Contact details for CQC and the local authority were identified in the service user guide. A person told us, “I know the boss, [registered manager], she is lovely; very easy to talk to and if I have an issue, I will tell her. I do see [registered manager name] most days.” Other relatives we spoke with had a great respect for the registered manager; they told us the registered manager was very approachable and sorted problems if they arose, quickly and with good outcomes. Relatives felt well informed about the home and any issues that may have arisen with their family member who lived in the home.

The registered manager ensured their office door remained open whenever possible, and staff felt comfortable in approaching them or the deputy manager. The registered manager invited conversations, questions and feedback from staff, people and relatives and carried out a daily stand-up meeting to stay connected to the team and to be made aware of important updates.

The registered manager completed audits with people to gain knowledge of their experience, and to demonstrate to them they were involved in their care and cared about their experiences; the registered manager took time to get to know people, relatives and team members individually and knew what mattered to them individually. At the time of the inspection there was no designated Freedom to Speak Up [FTSU] champion; the registered manager told us this was something they would definitely implement and felt the role would support openness, and encourage a culture where staff feel safe to speak up.

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.

Leaders provided flexible working agreements to staff to account for personal circumstances such as caring responsibilities and health issues. Leaders took steps to ensure staff were representative of the population of people being supported. Staff told us they were treated equally by leaders.

The registered manager ensured all staff had a voice via daily handover meetings and team stand up meetings. The registered manager asked for ideas and feedback from all the staff team and not just team leaders and addressed any conflict or misunderstandings when they arose and dealt with them promptly and fairly. Staff were encouraged to resolve disagreements respectfully and the registered manager reminded them of the shared goals.

The providers’ quality team completed staff surveys so staff could speak up freely and anonymously. There was a head of safeguarding staff member in place who was the providers’ FTSU guardian. The provider had an anonymous whistleblowing email address which all staff have access to, and people and relatives were signposted to CQC and local authority if needed.

Staff had access to equality training to help them understand about protected characteristics, bullying and harassment and relevant policies were in place, in-line with current best practice guidance.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Staff were clear about their roles and accountabilities and had regular opportunities to meet, discuss, and learn from the performance of the service. A clear organisational staff infrastructure was in place. People and relatives praised the registered manager and the staff team; one relative told us, “I couldn't speak highly enough of the manager, a very kind and approachable lady; she knows her job well. Just last week I had an issue with another resident. It was dealt with immediately and everything is back to normal. The atmosphere in the home is good for both staff and residents.”

There was a defined leadership and reporting structure and chain of command; this was displayed in the staff room. The registered manager was responsible for day-to-day operations, regulatory compliance, safeguarding, staffing and quality of care, and medication audits. A clinical lead was in place who oversaw clinical care and also completed medication audits and staff supervisions in partnership with the registered manager.

A regional manager provided support and oversight and monitored the strategic direction of the home; they carried out regular visits audits and checks of compliance, and reviewed key performance indicators such as staffing levels, incidents, complaints and quality outcomes. The regional manager supported the registered manager with the service improvement plan and any strategic decisions.

Team leaders were responsible for medication management and administration, updating care plans and risk assessments, the delegation of the staff, resident wellbeing, and completing a resident of the day audit. Each role had clear responsibilities and accountabilities.

The provider had a business continuity plan, which covered the relevant areas, in the event of an unforeseen emergency. Policies which were reviewed as part of this inspection were up to date. Daily handover meetings supported staff at all levels to work safely with people. Performance and risks were routinely discussed in staff and leaders’ meetings.

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.

The provider, registered manager and staff worked in partnership with local organisations and people were supported to engage with the local community, which had a positive impact on them. People’s daily lifestyle was identified in their care plans; this provided information on what each person was interested in and liked to take part in. A relative told us, “I could never have got through the last 3 years without the care and support of the manager and staff here at the home. They took care of me as well as [person]. Always around with a kind word, or just to hold my hand. Being the carer of a person with dementia is a lonely place and having the girls [staff] here with their love and support meant everything to me.”

We observed a meeting taking place in the activities area of the home between people and staff to talk about a Christmas open day event. The registered manager was also involved and encouraged everyone to contribute ideas for what they would like on the day. We saw lots of happy interactions between people and staff, with respectful conversations being held with people. It was clear people were very well involved.

The registered manager worked closely with a range of external partners to ensure people received safe, joined up, person-centred care. Partner organisations included: local authority social workers; the local authority Safeguarding Adults Board; therapy services such as speech and language therapists, physiotherapists and occupational therapists; community and advocacy organisations; and Bolton infection control team.

There was shared decision-making via multi-disciplinary meetings with GPs, nurses, mental health teams, and the supporting pharmacy. Any external advice was added to people’s care plans the same day and updated information was cascaded to staff through daily handovers and digital systems. People had hospital passports and comprehensive transfer documentation.

There were active links with a range of local community groups, schools, nurseries, and faith organisations. A local church provided pastoral support, and visited people for prayer, conversation, and spiritual comfort. The church also supported people during religious holidays and special services.

There were also strong partnerships with several local schools and nurseries who supported the home by visiting for singing, reading, joint activities, creating intergenerational projects, sending letters, drawings and card making during special occasions and involving people in seasonal events such as Christmas plays and Easter activities.

The registered manager also engaged with local wellbeing organisations, dementia buddies, activity-based charities and support services such as Age Concern and Bolton council fit for future. These links brought entertainment, specialist support, and community involvement directly into the home.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider had suitable systems and policies to ensure continuous learning and improvement. We noted lesson learned were in place and where concerns had been identified, these concerns were shared with the staff team. The registered manager was responsive to feedback from all sources.

The provider was committed in ensuring quality assurance was in place to maintain high standards of care and ensure the well-being of people being supported. There were clear and established standards for various aspects of care such as medication management and people’s safety. The provider and registered manager regularly reviewed incidents and any medication errors, and the necessary improvement actions were taken and recorded.

The provider regularly assessed the care provided through audits, internal quality assurance visits, and by analysing feedback from people and their relatives. Data including incident reporting and health outcomes was collected and analysed to identify areas for improvement. Clinical, residential and provider governance meetings were held regularly to identify areas of concern including employment, financial, strategic and corporate risks, with relevant matters being fed into appropriate operations meetings.

There was learning from any professional feedback received, such as from district nurses, hospital teams and safeguarding teams, and this was used to improve outcomes for people and improve service quality. A relative told us, “[Person] is safe and loved by the staff. The home try to cater for everyone and it’s not easy. They [staff] are always checking that I like the care, and food [person] has.” A person said, “I am surrounded by people [staff] who are always asking if I am ok.”

The provider adequately trained staff and they understood the quality standards and procedures. All staff we spoke with confirmed leaders encouraged them to speak up with ideas for improvement and innovation and actively invested time to listen and engage; we also verified this by looking at a range of meetings which had taken place throughout the year.

There was a service improvement plan in place which was reviewed and updated by the registered manager and the regional manager. This was reviewed regularly during regional visits to the home to ensure the registered manager stayed on-track and responded quickly to any changes or risks; the deputy manager, team leaders and staff were kept informed.

The registered manager attended a monthly provider call with the directors, the quality team, HR and recruitment to discuss improvements with the company and services provided. This helped to drive quality and compliance within the home. Feedback from people, relatives, staff and external partners was used to reinforce positive change and continuous improvement.