Woodleigh Rest Home Limited

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 Requires Improvement. 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 governance at the service.

This service scored 25 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The provider’s statement of purpose had not been updated since June 2023 and the information provided did not accurately reflect the current service provision. The vision and values of the service were stated; however, it was not clear how these were shared amongst staff or adopted in practice.

There was a lack of oversight to ensure people were supported appropriately and engaged in a way that was meaningful to them. Concerns found during the assessment relating to person-centred care had not been identified by the provider.

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.

There was a lack of effective oversight and management of the service which had impacted on the quality of people's care. Leaders, including the registered manager, did not demonstrate the skills and knowledge to support effective leadership, which the provider had failed to identify and address. For example, the registered manager lacked an understanding of regulations in respect of staff recruitment requirements and did not ensure robust checks were made before staff were employed to support people.

People, relatives and staff spoke positively about the registered manager. Comments included; “The registered manager promotes a positive homely environment which cascades down through the team” and “Registered manager is a good manager, [they] listen to us and are trying to get things in order.” However, concerns were also raised about staffing and the lack of action taken to address these shortfalls.

People did not feel they could speak up and that their voice would be heard.

Staff were aware of the whistleblowing policy and minutes showed this had been brought up at a staff meeting in June 2025. The minutes listed information that had been given to staff, however, did not evidence that staff were given any opportunity to raise any questions or give feedback. Shortfalls in governance systems meant we were not assured that all concerns were listened to, monitored and addressed.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had a diverse workforce in place, and staff had received training in equality and diversity. The registered manager gave an example where reasonable adjustments had been made to support a staff member.

The provider’s equality and diversity policy focused on the human rights of people using the service and not those of staff working in the service. We identified an incident of discrimination against a staff member which we reported to the provider and registered manager. The registered manager was already aware as the same incident had been reported previously. However, action had not been taken to ensure the discrimination did not re-occur and protect the staff member. The provider and registered manager said action would now be taken immediately.

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 failed to implement clear roles and responsibilities which impacted on the management of the service. The registered manager confirmed they and the deputy manager wrote and reviewed all the care plans and acknowledged they were struggling to complete all their managerial responsibilities. The deputy manager was also the activity organiser and worked as a senior care worker. These multiple roles impacted not only on care provision but also the management of the service. The provider had failed to identify or address this.

Effective systems and processes were not in place to assess, monitor, improve and sustain the quality and safety of the service. Matters identified through the assessment process had not been picked up or addressed through the management team’s quality checks. For example, medicines safety, staffing, recruitment, quality of recording, person-centred care and managing risks to people’s safety. Provider oversight of the service was not robust and failed to take action to address issues identified and make improvements. The provider informed us they were taking action to address concerns following our assessment findings.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

A lack of oversight and monitoring at the service impacted the effectiveness of collaborative working and sharing of information, as learning and quality improvement was not routinely taking place. People’s care plans were not always up to date, detailed and accurate therefore we could not be assured that partnership working was always fully supporting effective care.

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.

There were no effective systems in place to ensure continuous learning and improvement at the service. Our assessment found widespread and significant shortfalls which the provider had not identified or addressed through their quality management systems.