Woodlands Care 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 good. 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 service was in breach of legal regulation in relation to good governance.

This service scored 36 (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 provide the support staff needed to work towards a culture of equity, equality and human rights, diversity and inclusion that fully understood the challenges and needs of people using the service. People, relatives and staff consistently described a culture where they did not feel listened to, valued or supported. One relative told us, “A lot of people, including staff, have not been getting enough support from the management hierarchy. As a family member, I’m listening to them. I see residents just sitting there and doing nothing. It’s very sad.” People and relatives consistently told us the service did not meet their expectations and feedback about the management of the service was predominantly negative. Staff morale was low, and staff told us they did not feel valued by the management team. One staff member said, “Everyone [staff] are so angry. They do what they want and don’t care because they don’t feel listened to or valued.” This demonstrated the provider had not established a positive and inclusive culture where people, relatives and staff felt engaged, respected and able to contribute to service improvement.

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. Feedback from people, relatives and staff reflected the impact of prolonged instability in leadership. One relative told us, “The home is completely managerially ineffective. The last manager walked out a year ago. I met the new manager yesterday. There have been some 4-5 interim managers before her.” Another relative said, “[New manager] wants to get things done and improve what is going on for residents. I think it will improve. I don’t think it’s been well run at all. It needs to be better managed. I hope the new manager will do better.” Staff also described frustration with how they had been treated and reported a lack of consistent leadership and support. Further work was needed to ensure reporting lines, accountability and leadership responsibilities were clear and understood throughout the service. The new home manager, who was awaiting CQC registration, was open and honest about the challenges facing the service. She told us, “There have been issues with inconsistent leadership and lots of interim managers over the past year and that has dramatically impacted the service. My main focus has been on doing observations and trying to understand what is actually going on the ground.” She demonstrated insight into the issues affecting the service and a commitment to improving visibility, accountability and management oversight. However, it was too soon to assess the impact of these changes.

People did not always feel able to speak up and be confident their views would be heard and acted upon. Feedback from people, relatives and staff consistently indicated concerns were not always listened to or responded to effectively. Although relatives' meetings were in place and some relatives found these useful for peer support, views were mixed about whether they resulted in meaningful action or improvement. There was a whistleblowing policy in place, but some staff told us they felt uncomfortable or fearful about raising concerns. Staff also reported being discouraged from being fully honest when speaking with inspectors. This created a culture where people did not always feel safe to speak up, limiting opportunities for learning, transparency and improvement.

The provider did not always promote an inclusive and equitable culture for its workforce. Staff consistently told us they did not feel listened to, valued or supported by leaders, and morale was low. Some staff described feeling unable to raise concerns openly and lacked confidence that concerns would be acted upon. The provider had not consistently engaged with staff to understand their experiences or used feedback effectively to drive improvement. As a result, leaders could not demonstrate they were actively fostering a workforce culture that was inclusive, supportive and representative of the organisation's values. The new home manager recognised these concerns and had begun taking steps to improve staff engagement, visibility and support, although it was too soon to assess the impact of these changes.

The provider did not have clear responsibilities, roles, systems of accountability or effective governance arrangements. They did not always act on information relating to risk, quality and performance to drive improvement and ensure people received safe, high-quality care. Oversight of care planning, risk management and care delivery was ineffective. Although audits and monitoring processes were in place, they had not identified or addressed several concerns found during the inspection. Audit actions were not always specific, monitored or completed, resulting in known issues relating to care planning, risk management and the environment remaining unresolved. Greater clarity was needed regarding management roles and responsibilities, to ensure accountability and effective oversight. Governance systems required strengthening to provide assurance that concerns were identified promptly, addressed effectively and improvements sustained. The management team acknowledged significant improvements were required. During the inspection, the provider updated its Service Improvement Plan, and the new home manager told us she felt supported by the provider to drive the necessary changes. However, many of the planned actions were at an early stage, and it was too soon to assess whether improvements would be embedded and sustained over time.

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. Referrals had been made to external health and social care professionals when specialist services and guidance was required to promote people’s well-being. However, not all advice and guidance given by external health professionals was responded to by staff in a timely way. Records we reviewed showed advice and guidance given by professionals was not always shared with all staff. This meant people’s care and support were not always delivered in line with their most up-to-date assessed needs.

The provider did not focus on continuous learning, improvement and innovation across the organisation. Systems for recording and reviewing incidents, safeguarding concerns, complaints and feedback were not robust, and information was not consistently analysed to identify themes, trends or opportunities for improvement. Where incidents occurred or concerns were raised, these were not always investigated or followed up appropriately. Learning was not consistently identified, shared or embedded into practice, resulting in missed opportunities to improve outcomes for people and reduce the risk of similar issues recurring. Concerns raised by people, relatives and external professionals had not always resulted in timely action or sustained improvement. The provider could not demonstrate an effective approach to learning from incidents, concerns and feedback to drive continuous improvement or improve the quality and safety of the service.