Woodley Hall 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 the regulation relating to good governance.

This service scored 62 (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 management team were visible, knowledgeable, and supportive, providing guidance to help staff develop in their roles. Staff told us they received the training they needed to carry out their roles effectively and felt confident in the support provided by the management team. Staff comments included, “I am provided with comprehensive and ongoing training that covers all aspects of my role. The service is very well managed. The leadership team is approachable, supportive, and provides clear direction.”

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.

There was visible and clear leadership in the service. Staff knew who to go to if they needed support and told us the registered manager and deputy manager were approachable and supportive. A staff member said, “I have always felt supported by management and colleagues. Supervision and training are regular and helpful. The leadership team are approachable and open to feedback. Overall, Woodley Hall is a well-led, caring home with a strong team ethos.”

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

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

People and their relatives were invited to attend regular meetings where information about the service was shared. The registered manager encouraged feedback and suggestions to help improve people’s experience of care.

Staff felt able to raise any issues and felt these would be listened to by management. Their comments included, “We hold regular team meetings and supervision sessions where we can share ideas and provide feedback. The management actively encourages us to speak up about any areas that could be improved.”

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 received training in equality, diversity, and inclusion. They were encouraged to share concerns and ideas through regular supervisions, appraisals, and team meetings. Staff told us they felt valued by the organisation and described a positive team culture where everyone worked well together to support people’s needs.

The provider had systems in place to assess and monitor the quality of the service. Various audits were carried out by the management team to assure themselves of the quality and safety of the service people received. Whilst audits had been completed, they had not identified any of the concerns raised during this assessment.

The provider had not submitted the required notifications to CQC following safeguarding incidents, as required by their registration. Oversight and audits had not identified the lack of notifications submitted to CQC, which meant regulatory requirements were not consistently being met.

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.

The service worked in partnership with other health and social care professionals to meet people's needs. Records evidenced appropriate healthcare referrals and appointments. A healthcare professional told us, “The management team at Woodley Hall are highly responsive, approachable, and efficient. Any requests for information or support are handled promptly and professionally.”

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.

There were systems to ensure lessons were learned when things went wrong. Accidents, incidents and safeguarding concerns were reviewed and analysed to identify any emerging themes or patterns. Where necessary, changes were made to practice reducing the risk of recurrence and improving outcomes for people using the service.

Information and learning from accidents and incidents were shared with staff through regular team meetings and daily handovers. This helped ensure staff remained informed and supported a consistent and proactive approach to safety and risk management.