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 inadequate. At this assessment the rating has remained 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 regulation in relation 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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. Governance systems and leadership oversight had not established or maintained a culture that prioritised safe, person-centred care. There was limited evidence of a shared understanding of risks or priorities across the service, and repeated incidents had not resulted in consistent learning or sustained improvement. Care planning and documentation did not reflect clear expectations about quality or person-centred care. There was inconsistency in how staff delivered care. While some staff demonstrated compassionate and person-centred approaches, others adopted more task-focused practices. Relatives recognised the efforts of staff, with comments such as,“The staff bend over backwards trying to help,”and“They work really hard.”Concerns were raised by some relatives about the level of support available to staff, with one relative stating,“Staff could do with more support from management. Staff described the manager as approachable and the staff team as supportive. One staff member told us,“I would be happy for my family member or friend to receive care from this service.”

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. Although the Registered Manager was described by staff as approachable and supportive, this was not reflected in the overall management of risk, quality or compliance. Leaders had not maintained effective oversight of key areas of risk, and significant concerns identified during the assessment had not been recognised or addressed through management systems. There were gaps in leadership knowledge and understanding of safety requirements, including around hazardous substances and flammable creams. The registered manager demonstrated awareness of some areas requiring improvement, including plans for redecoration and additional infection prevention and control training. However, these actions had not translated into consistent improvements in practice, and expected standards were not reliably maintained. Feedback from relatives reflected a mixed picture of leadership visibility. Some relatives reported regular presence and accessibility, stating,“Every time I have been there, the manager has been around,”and“If I go in the week, they are there and contactable if needed.”Others experienced limited visibility, commenting,“I don’t often see them, but they keep in touch by phone,”and“I haven’t seen them apart from Christmas. I don’t think they are present much.” Staff consistently described a positive leadership style, with comments such as,“The manager is very supportive, motivating and approachable,”“Staff morale is very good. The team is supportive and the manager is fair and approachable,”and“There is a strong sense of trust between staff and management.”However, these positive perceptions were not supported by effective systems or oversight, and had not resulted in safe, consistent or well-governed care.

People did not always feel they could speak up and that their voice would be heard. Significant concerns relating to safety had not been effectively identified or escalated through internal systems. There was limited evidence of structured systems to capture and respond to staff feedback. Records did not demonstrate how concerns raised by staff were formally recorded, reviewed or used to drive improvement. This reduced assurance that staff voice was systematically used to identify risk or improve the quality and safety of the service. Although staff described a positive culture where they felt able to raise concerns, this was not consistently reflected in how concerns were identified, escalated or acted upon. Staff reported that they felt comfortable approaching the Registered Manager and raising issues. Comments included,“I feel comfortable speaking to them at any time,”and“We are encouraged to speak up and share ideas or concerns, and we feel listened to.”One staff member also said,“I am confident they would be addressed as the management are very approachable.”

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. There was limited evidence of structured systems to monitor workforce wellbeing, equality or inclusion, or to ensure that all staff were treated fairly and supported consistently. While staff described a supportive team culture, there was limited evidence that workforce feedback was used to identify potential inequalities, inform improvement or use structured approaches to promote equality, inclusion and fair treatment across the workforce. Staff told us colleagues worked well together and felt supported by the manager and wider team. There were some positive person-centred approaches within day-to-day care. The registered manager and staff described respecting people’s individual cultural and religious needs.

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. There was a lack of robust oversight, and systems had not identified or addressed significant and widespread concerns. We identified multiple areas of concern, including unsafe medicines management, poor infection prevention and control, environmental hazards, inconsistent care delivery, ineffective risk management and repeated incidents of harm. These issues had not been addressed through the provider’s governance systems. Governance records did not provide an accurate reflection of the service and presented an overly positive picture that was not consistent with our findings or concerns raised by external agencies. Records were not consistently accurate, complete or reliable, and safeguarding systems were not effectively overseen. Oversight of staffing, training and competency was also limited. Although activities were recorded and feedback systems were in place, we did not observe consistent delivery or evidence that feedback was used to drive improvement. Some relatives told us they had concerns about resourcing and oversight. One relative stated,“Resources seem insufficient. They need more support there,”and another commented,“Staff could do with more support from management.”

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. Systems to engage with external agencies and respond to shared information were not robust, which impacted on the safety and continuity of care. There were failures in working effectively with safeguarding partners. Safeguarding concerns were not always referred to the Local Authority in a timely manner, and CQC notifications were delayed. In some cases, appropriate referrals were only made following external intervention. Information shared by safeguarding partners raised concerns about falls, hygiene and care delivery within the service. These concerns were consistent with our findings but had not been effectively analysed, responded to or used to improve practice.

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, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. Systems to support learning and improvement were not effective. Repeated incidents had not resulted in sustained improvement, and although actions were identified, there was limited evidence these were consistently implemented or monitored for effectiveness. Learning was not embedded into day-to-day practice. There was limited evidence of proactive service development, and feedback from incidents, staff, relatives and external agencies was not consistently used to drive improvement.