Woodview Care Centre

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.

This is the first assessment since the provider of this service changed. This key question has been rated inadequate. The service was in breach of legal regulation in relation to governance at the service. 

This service scored 36 (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 proactive and positive culture based on honesty. They did not listen to concerns about safety and did not investigate or report safeguarding concerns. Lessons were not learnt to continually identify and embed good practice.

There was a lack of accurate recording or robust processes for the management team to review accidents and incidents. We found this lack of review had led to required actions not being taken to improve outcomes for people.

The provider and acting manager had supported a closed culture. They had failed to inform external agencies of incidents where people were at risk of abuse. The acting manager had not ensured thorough investigations had taken place when concerns were raised. They did not give the same weight to the voice of people using the service that they did to staff.

The culture of the service had not put people at the centre of the care provided. The acting manager and staff did not have a good understanding of people’s rights.

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. Managers did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

There had not been a registered manager at Woodview Care Centre since July 2024 which had impacted on the quality of the service. Managers showed a lack of oversight, despite the acting manager’s long service at Woodview Care Centre. The acting manager and area manager showed compassion and empathy but lacked strong management skills.

Although staff felt they could approach managers with concerns and they would be addressed, managers were not always proactive in identifying poor practices that could impact the quality of people’s care and well-being.

However, some people we spoke with told us they knew who the acting manager was, and they were approachable. A person told us, “She’s often around and very easy to chat with.”

We found the service lacked an open and transparent culture. We could not be assured of the freedom to speak up. Due to our findings that safeguarding concerns were not always reported by staff or identified by the provider, we could not be assured people, and their relatives would be informed of these promptly.

Staff understood how to raise concerns if they felt the management team had not satisfactorily responded to them or people. However, the lack of quality monitoring in place meant there was no overall service improvement plan to improve care quality across the service.

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 told us they were supported to work flexibly, which ensured they had a good work life balance. There was evidence of reasonable adjustments in place to support people with long term illnesses or conditions to enable them to work.

Some staff felt the service showed value to them, however not all staff felt they were equally supported as managers were not always present at the times they worked.

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.

Managers did not ensure governance systems were effective, and appropriate actions were taken to improve the safety and quality of the service.

All the audits we reviewed failed to have action plans to evidence identified shortfalls had been improved to ensure the quality and safety of the service was appropriately monitored.

Managers did not assess, monitor and mitigate the risks relating to the health, safety and welfare of people. The monitoring of accidents was not sufficient to ensure accidents were appropriately analysed to mitigate the risks of people suffering injury from falls.

Actions were not taken when staff did not support people in line with their assessed needs which was evident in accident forms.

Managers did not assess the quality of accident forms to ensure they were completed timely following the incident and that actions taken to mitigate risks were appropriate. Accident forms were often duplicated or completed on a different day which gave a skewed version of events and impeded accurate oversight of risk.

Managers had not ensured care plans contained the most up to date information and that terminology used in care plans was appropriate and respectful. Care plan reviews were delegated to other staff and oversight was minimal to ensure these were effectively completed. The acting manager told us they were aware the quality of care plans was not to a good standard and stated they were not completed as they wanted. However, actions had not been taken to address this to improve the quality and accuracy of care plans and to ensure the content was respectful and dignified.

Systems were ineffective to safely recruit staff. Systems had not identified gaps in employment which meant staff were not safely recruited which put people and staff at increased risk of harm. Training records were not kept up to date to identify whether staff had completed their training and if it was in date.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. The service did not always demonstrate they understood their duty to collaborate and work in partnership, to promote services working seamlessly for people due to the safeguarding concerns we identified during this assessment.

However, people and their relatives told us they received support to access services from other health care professionals as needed, such as their GP or chiropodist.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system.

Incidents and complaints had not been analysed by the management team to look for themes and patterns. Actions taken by the service lacked analysis so these could not be shared in team meetings with staff for them to embed learning and improve care outcomes for people.

Staff told us they undertook training to support them in their role. However, we saw evidence that not all required training had been completed and there was insufficient oversight to ensure staff were completing or keeping their training in date.

There were no effective systems in place to drive improvement and quality assurance processes were ineffective.