Woodside Nursing 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 inspection we rated this key question good. At this assessment the rating has remained good.

This service scored 71 (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 provider had information on their website about their vision and missions, and this was displayed within the service. For example, the provider’s vision for the future includes, “To provide the highest quality of care while maintaining the personal touch that has defined Cedar Care Homes for over three decades. We continuously invest in our homes, our people, and our services to ensure we meet the evolving needs of our Residents.”

There was a business plan in place which included a strengths, weaknesses, opportunities and threats (SWOT) analysis. Leaders were alert to the challenges around ‘closed cultures’ within the service and had put several interventions in place to ensure this did not happen. One of the interventions included changing staff rotas to ensure the same staff were not always on the same shift together to prevent closed cultures happening in the service.

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. Overall, people and partners we spoke with were positive about the leaders at the service. Staff told us the leadership structure in place was effective and one staff member commented, “They are approachable, and encourage us to communicate any concerns with them.”There was a leadership structure in place to support the delivery of the service. The manager understood their regulatory responsibilities and was going through the registration process with CQC to become the registered manager. The manager told us about the support they had received from senior leaders since commencing in their role and demonstrated a caring attitude towards staff and people living at the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were aware they were able to speak up and policies were in place to support this. They told us they had opportunities to speak up and have their voice heard during supervisions and team meetings. We reviewed evidence of team meetings and supervisions where open discussions and actions were documented. Staff felt able to approach leaders to discuss any concerns they had. There was a whistleblowing policy and procedure in place.

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. Staff were complementary about the way the service led on workforce equality, diversity and inclusion. One staff member told us, “In our home there are different staff from different nationalities, this literally helps us all to learn more things.” The provider told us, “We try to balance the number of people we have in each home from different backgrounds, so there are not too many of a certain nationality in each home which helps balance equality and diversity. We have our core standards which we expect all staff to work towards.” There were examples of where the provider had organised days for staff and people who use the service to learn more about the different cultures of staff. One staff member also gave us an example of when the service supported them with changes to their working hours when they were going through a difficult period. Equality, diversity and inclusion training had been completed by staff and there was a policy in place.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. For example, IPC audits had not identified the minor concerns we found on the day of the inspection. Care plan audits had not identified the interchange between ‘him’ and ‘her’ in a person’s care records. Furthermore, although medicine room temperatures were being recorded and audited, with temperatures recorded as being consistently higher than NICE guidance, actions to resolve this issue had not been successful. The provider had not considered any other alternatives to reduce the temperatures in the medicines room until the day of our onsite visit. This meant the provider could not assure themselves that people’s medicines were stored correctly and were fit for purpose at the point of administration.Immediate action was taken by the provider in the areas of concern identified during the inspection and leaders told us they would look to further strengthen their approach on governance by completing a lesson learnt analysis and communicating this with the team.

However, there was evidence of other regular audits which were effective, and governance, management and accountability arrangements were in place.

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. People told us the service worked with other partners on their behalf. Professionals confirmed the service worked with them to improve care for people. We saw evidence of regular referrals and communication with partners. There was a schedule of regular activities taking place and a volunteer had been visiting the service for several years to support people’s well-being. Opportunities were available for people to go out monthly with the well-being team to access events in the community and there was a minibus with access for wheelchairs to ensure people could participate in their community during outings and events.

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.

Staff told us, “Leaders are open to hearing new ideas, we can always pass it on to the person in charge and ideas are discussed during general meetings.” The provider had commenced an initiative called the ‘Dream Maker,’ this is where a staff member nominates a person living at the service to have a dream come true. Staff completed an application form about something that would mean a lot to a person, the service reviews the application and then provides the funds for it to go ahead.The provider was also working with a software development company to design care planning tools specific to the organisation’s requirements. They were also in the early stages of experimenting in the use of care technology to enhance productivity and outcomes. For example, an electronic system called acoustic monitoring was being used which monitored sounds from people’s rooms for potential concerns without the need for intrusive checks. Environmental sustainability practices such as a programme to retrofit solar and battery arrays on roofs were taking place and the provider was trialling electric vehicles throughout all its services. The provider was also registered with ENRICH (enabling research in care homes), a national initiative supporting research in the care home sector, and the manager told us they would be engaging in this programme soon to see how it would benefit of the service and the people who used it.