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 inadequate. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.
 

This service scored 68 (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 culture within the service had improved and was positive. Staff demonstrated understanding of the service’s values, which were reflected in their practice. It was clear work had been undertaken to improve the culture following previous assessments.
 

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.

Staff spoke positively about the management team and told us they felt supported in their roles, which contributed to a more positive working environment. All staff reflected a clear improvement since the last assessment, with staff feeling more confident in management, describing them as visible in the service and “approachable and fair.”

The manager was developing in post and had been supported by the provider and external resources to strengthen their leadership. Leaders were open and transparent about areas where further improvement was required and demonstrated a willingness to act.

People also spoke positively about the manager, with 1 person telling us, “[Manager] has been really good at getting things sorted out for me, I have an electric scooter and [manager] is getting it checked over so I can use it outside. I didn’t have to ask for this, they volunteered.”
 

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

Staff knew their responsibilities for safeguarding people and told us they felt able to raise concerns around the safety of people. Staff had completed safeguarding training, had access to the whistle blowing procedures, and were confident action would be taken.
 

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.

The service promoted a fair and inclusive working environment through the delivery of training and inclusive practices. Staff told us they felt treated equally and had not witnessed discrimination. Recruitment processes supported equitable access to employment, and the provider had developed a diverse workforce.
 

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.
Governance systems were not consistently effective in identifying and addressing risks. Audit findings were often overly positive, lacked sufficient detail and did not always reflect the reality of practice. For example, care plan audits indicated records were accurate and up to date; however, during the assessment we identified gaps and inconsistencies. Similarly, environmental checks had not identified issues we observed. In addition, there was no system in place to collate and analyse behavioural records, meaning patterns could not be identified and the provider could not be assured appropriate approaches were consistently used. This meant the provider did not always have clear assurance regarding the quality and safety of the service.
However, some governance systems in place were effective. For example, regular audits and oversight processes in areas such as medicines management and incident analysis supported the identification of issues and ongoing improvement. Management presence within the service, including daily and weekly checks, also contributed to a level of oversight.
 

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.
Partnership working had improved. Professionals told us communication was effective, and we saw evidence of strong working relationships with health professionals, including dieticians, GPs and district nurses. Community engagement was less developed but was planned for future improvement.
 

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider had taken steps to learn from previous assessments. Action plans were in place and regularly reviewed. A range of systems had been introduced to improve oversight, and the provider worked effectively with external stakeholders to improve outcomes.
Some improvements were becoming embedded; however, others remained inconsistent in practice. Although the provider worked with a wider provider group, there was limited evidence of how shared learning was consistently recorded and applied in day-to-day care.