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 good. At this assessment the rating has changed to 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 service was in breach of legal regulation in relation to good governance.
 

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 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.

Staff felt there was a positive culture at the service where they felt valued and listened to. The provider worked with the staff team to build open and transparent relationships; this was demonstrated through staff meeting minutes that we reviewed.

During our on-site visit, we observed a friendly and caring atmosphere throughout the care environment.

People and their relatives were provided with clear information on how to raise suggestions and concerns about the service.

Leaders did not always have the skills, knowledge, experience to lead effectively.

The management team were approachable and were passionate about their roles and making a difference to people’s lives who use the service. However, management oversight of governance demonstrated a lack of skills and knowledge to ensure national guidance and regulations were always followed.

The management did not have a clear understanding around the application of the Mental Capacity Act 2005, which resulted in incorrect procedures being followed when people lacked the ability to make certain decisions for themselves.

A further example, the management team acknowledged that they lacked sufficient knowledge and training around the application of clinical tools to assess risks in relation to malnutrition and dehydration. They recognised this as a shortfall and confirmed that they would source additional training and support for the staff from the district nursing team.

Therefore, we were not assured that all leaders had full knowledge and experience of the requirements of the regulations.

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

Staff were positive about working at Woodlands Care Home. Staff we spoke with told us they felt able to raise anything with the management team and felt they would be listened to. Comments included, "If I notice anything I have the right to speak up and so do residents" and "I feel I have the freedom to speak up".

Whistleblowing policies were available for staff with advice about who to contact if they had concerns.

People and family members as well as external professionals felt able to raise any concerns with the management team.

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. There was an inclusive and fair culture with equality and equity for staff.

Management told us they fully supported flexible working and this was evident on staffing rota's. Staff were positive about working at Woodlands Care Home and felt they were treated with respect.

The management team valued diversity and ensured best practice guidelines were followed. Staff received training about equality and diversity, and the provider had policies in place relating to equality and diversity.

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.

The provider had a range of quality monitoring procedures in place including audits of various aspects of the service. However, audits and governance procedures were not effective and had not identified the issues we found during the inspection as detailed in the various sections of this report.

Governance systems to oversee that care was carried out in line with people’s assessed needs and that care records were sufficiently accurate to reflect people’s experiences were not effective. The systems and processes in place failed to ensure people’s records were always accurate, complete or contemporaneous. We found examples where people’s care records were incomplete, insufficiently detailed, did not accurately reflect people’s experiences and did not contain sufficient information for staff to manage people’s specific needs or conditions. Risk assessments had not always been completed for known risks and people were not always repositioned as per their assessed need.

The provider failed to have robust and effective systems in place to oversee health and safety at the service. This included oversight of delegated tasks in relation to environmental risks including water safety. Water temperature audits failed to identify that water temperatures were not being recorded, therefore records failed to demonstrate that water being dispensed was within the safe temperature ranges. Fire door audits were not robust or effective and did not identify the areas of concern related to fire door safety. Calls bell audits did not identify missing call bells in people’s en-suites. Maintenance audits failed to identify window restrictors that were missing in areas that required them and exposed hot pipework, placing people at risk of harm.

Additionally, the concerns we found in relation to safe medicines management and mental capacity assessments had not been identified through the providers audits.

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.

Staff and the management team were open and transparent, and they collaborated with all relevant external stakeholders and agencies. The service worked in partnership with health and social care professionals to achieve good outcomes for people.

A professional commented, “When I first came out, first year [2 years ago] moral low and depressing place. Since [registered manager] started atmosphere is nicer”, “When I ask them to do something, they are very responsive” and “Don’t worry about this service, very nice and refreshing. No concerns and quite rare.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

The provider did not have an effective system or plan in place to monitor and improve the quality and safety of the service. Monitoring systems were not effective and had not identified the issues we found during the inspection as detailed in the various sections of this report.

The management team were open to the feedback we gave throughout the assessment and showed a willingness to improve when shortfalls were identified.