Woodland Grove

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 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 provider was in breach of a legal regulation in relation to 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. The culture of the service was warm, open and transparent. Staff demonstrated a passion for providing good quality care and were proud to work at the service.

The provider had inclusive leaders, but they did not always understand the context in which they delivered care, treatment and support. Leaders did not always have the knowledge needed to lead effectively. The registered manager did not always recognise and address safety issues including environmental safety concerns. While we had confidence in the registered managers ability to reduce risk following our feedback, further improvement was needed to ensure they retained overall oversight of all aspects of care provision and developed a more effective monitoring system that was proactive in identifying and reducing risk in a timelier manner.

The provider stored electronic records across multiple systems. During the assessment, the registered manager could not always readily access all relevant records. Some further improvement was needed to ensure leaders were clear on where records were held and these were easily accessible to improve the running of the service.

However, the registered manager and team leaders were compassionate and demonstrated an in-depth knowledge of people's needs. Overall, they promoted the delivery of high quality, person-centred care that fit the Right Support, Right Care, Right Culture model.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff had access to a handbook which guided them on the processes they should follow to raise concerns. All staff told us the registered manager and team leaders were approachable, and they could share concerns openly. Comments included, “[Registered Manager] has an open-door policy, he is very approachable by email, phone and face to face."

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. Different cultures, faiths and backgrounds were represented within the staffing team. Difference was respected and celebrated.

The provider did not implement effective governance systems, and they did not always have clear systems of accountability and good governance. Overall, there was a lack of effective oversight and scrutiny of the service by the provider and the registered manager to ensure risks were identified and acted upon. Audits and checks were completed; however, they were not effective at improving the quality and safety of the service as they failed to identify all concerns found during the assessment. For example, checks undertaken on the safety of the environment, medication management and infection prevention and control (IPC) did not identify the shortfalls we found. The absence of effective audits increased the risk to people’s health and safety as opportunities to identify concerns were missed and risk was allowed to continue unchecked, as evidenced by our findings.

Where concerns had been shared by external professionals, we identified action was not always taken to improve. For example, an external IPC audit carried by the local authority in February 2025 found concerns with cleanliness of sealants in bathrooms and chipped paintwork. We saw action was taken following this audit to remedy these issues. However, our assessment found similar concerns and therefore, the previous audit had not led to sustained improvements in the service.

The registered manager and provider were responsive to our findings and developed a robust action plan to improve governance systems.

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. Overall, leaders were open and transparent, and we saw evidence they collaborated well with relevant external professionals. We received positive feedback from professionals who worked with the provider who described good communication and partnership working.

The provider did not always focus on continuous learning. Auditing systems were not implemented effectively to drive improvements and promote continuous learning. However, the registered manager and provider were receptive to our feedback. They worked hard to address concerns to improve the quality and safety of the service in a timely manner and have demonstrated they have completed a thorough action plan to drive improvement in the areas of key concern.