The 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 our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider was in breach of the legal regulations relating to good governance.

This service scored 32 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The findings from our assessment indicated the culture of the home was not person-centred. There were instances where people’s basic care needs were not being met adequately or in line with their preferences. Staff were very busy and task orientated leaving little time to sit and engage with people. People were not always included in decisions about their care and their independence was not always promoted.

Staff feedback revealed concerns about the culture and direction within the service. In particular, regarding staff living within the service and the lack of consultation. There were widespread failures across the service and the culture did not promote people’s safety or increase their experience of good care.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

There has been no registered manager in post for over 619 days, the current manager has been in post for over 12 months and had commenced the process of registering with the Care Quality Commission. Whilst new systems had been created by the manager, these proved to be ineffective and failed to identify the concerns found during the assessment. For example, people who experienced falls or incidents, an accident form was always completed by the staff team, however, the review of the incident did not look for themes or trends or explore reasons for falls and there was a lack of action to mitigate future incidents.

People did not feel they could speak up and their voice would be heard. Staff feedback varied with some staff feeling confident to speak out, and others chose to not answer. One staff member did say, “There is encouragement to speak up, the manager is approachable.”

Supervisions were not held regularly for staff to share their views and raise concerns. All supervisions viewed were not personal to the staff member and duplicated for all staff. Staff told us they were told about changes after they had happened, and were not discussed with them, therefore staff did not feel their views were valued and they did not feel supported by the provider.

These were missed opportunities to identify trends and to take appropriate actions to address them and improve staff, and people’s experiences.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider employed a diverse workforce. Some staff had been working at the home on sponsorship from abroad. However, the provider had not ensured a consistent approach to ensure the continuous management and oversight of all staff, to make sure all staff member’s specific support and training needs were identified and met. For example, one staff members supervision records consistently identified concerns with the administration of medication. There was no record of what actions were taken to support the staff member, or what training and supervision had been provided. The records continued to highlight the concerns without evidencing any action.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. For example, the governance systems in place had failed to ensure a consistently good service was delivered and had not identified the widespread shortfalls identified at this assessment. Risk management was poor and there was a lack of analysis to establish the cause and if any lessons could be learnt and shared with staff to prevent a recurrence.

The provider and manager did not always identify and mitigate risks to people’s safety. Documentation was not accurate or complete and did not reflect people’s needs. All audits observed were scored as fully compliant with no actions recorded, they appeared to be used as a tick box exercise rather than a tool to determine and highlight areas of improvements. Areas of the service were not safe and placed people at risk of harm, there was a lack of oversight, accountability and governance. This was a breach of Regulation 17 (good governance).

The provider did not always work effectively to ensure people received safe care.

Care plans and risk assessments did not reflect people’s current needs. Therefore, it was unclear how accurate information was being shared with other health professionals involved in people’s care.

People and their families expressed concerns about a lack of collaboration with external organisations and community access. There was no evidence staff actively supported people to integrate into the wider community, such as facilitating attendance at local dementia cafés or community groups. This limited opportunities for people to maintain social connections and benefit from wider community resources, events and groups.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcomes and quality of life for people. They did not actively contribute to safe, effective practice and research.

The Local Authority had completed an assessment of the service in May 2025 and had provided detailed feedback. The themes of improvement identified following their assessment remained in place during our assessment and there was little progress evident with actions identified. Despite being given opportunities and support from the local authority for improvement, the service had not used these to ensure people’s experiences and care provision was safe and of good quality.

Staff did not benefit from frequent structured supervision, feedback or embedded lessons learned discussion to reflect on practice to develop their approach to providing person centred care. There was no evidence that lessons had been learned from accidents, incidents, or falls, due to the absence of meaningful action to review and analyse these events for trends, patterns, or opportunities for improvement.

Quality assurance systems were ineffective, which limited the provider's ability to drive improvements that promoted equity and positive outcomes for people.