Foxwood Lodge Residential 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.

This is the first assessment for this newly registered service. This key question has been rated 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 86 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

Leaders promoted a therapeutic approach, and staff understood their role in supporting people to achieve greater independence and move towards less restrictive lives. The culture of the service was focused on achieving positive outcomes for people. During the assessment we found examples of people being supported to reduce restrictions, move towards supported living, access education and develop greater independence.

Staff spoke positively about the culture of the service and demonstrated a commitment to helping people achieve meaningful goals and remain connected to their communities. There were systems in place to communicate expectations and learning, including regular team meetings, supervisions, handovers and daily huddles. Staff told us they felt able to raise concerns and contribute ideas about improving the service. One staff member said, "I feel confident in doing everything here and raising any concerns."

The provider had exceptionally 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 always did so with integrity, openness and honesty.

Leaders were highly visible, knowledgeable and passionate about improving people’s lives. People, staff, relatives and healthcare professionals consistently provided positive feedback about the leadership team and their commitment to achieving the best possible outcomes for people. The registered manager demonstrated a detailed understanding of people’s needs and was responsive throughout the assessment process.

Staff told us they felt supported by leaders and valued within the organisation. The provider had introduced opportunities for staff to meet informally with leaders, share ideas and discuss concerns. Leaders also promoted staff wellbeing through initiatives including wellbeing sessions, staff awards and recognition events.

Healthcare professionals spoke exceptionally positively about the leadership team's approach. One professional told us, "Their focus was always on achieving the best possible outcomes for the young person, tailoring support packages to meet individual needs, and ensuring that the person remained at the centre of every decision." Another healthcare professional told us, “The difference they make to people's lives is extraordinary, and they should be immensely proud of the care, compassion and commitment they show every day.”

Leaders demonstrated compassion and accountability when concerns arose. They responded promptly to inspection findings, took immediate action where required and showed a willingness to reflect, learn and improve systems. Feedback from people, relatives, staff and professionals consistently described leaders as approachable, responsive and supportive.

The provider encouraged an open culture where people, relatives and staff could raise concerns, share feedback and express their views. There were a range of opportunities for feedback, including resident meetings, staff meetings, surveys, key worker meetings, complaints processes and informal discussions with leaders.

Staff demonstrated an awareness of whistleblowing processes and told us they would feel confident reporting concerns. One staff member said, "If a staff does something against rules and regulations I would blow the whistle." Staff also told us they felt confident raising concerns directly with managers.

The provider displayed freedom to speak up and whistleblowing information around the service.

People and relatives could also raise concerns and receive feedback.

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 provider recognised the importance of equality, diversity and inclusion and took steps to promote an inclusive culture for staff and people using the service. Leaders delivered themed learning events and awareness activities covering topics such as gender identity, sexuality, disability and cultural diversity. Staff told us managers treated people fairly and listened to staff regardless of their background. A staff member told us managers were "always listening to us regardless of colour and race."

The provider also promoted inclusion through culturally responsive care and by celebrating diversity within the home. People were supported to express their identities, practise their faith and maintain cultural traditions important to them. Staff received information and guidance intended to help them support people respectfully and inclusively.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There were systems for gathering feedback from people, relatives and staff, and leaders reviewed a range of information to identify themes and areas for improvement. The provider also had business continuity arrangements, environmental checks and systems to monitor health and safety risks.

The provider had governance and assurance systems in place to monitor quality, safety and performance. These included audits, quality checks, governance meetings, action plans, provider oversight visits, daily huddles and regular reviews of accidents, incidents and safeguarding concerns. However, some governance systems were not always fully effective. During our assessment we identified ongoing concerns regarding medicines storage temperatures that had previously been recognised through audits but had not been fully resolved. We also found some recording issues relating to incidents and care notes that required further improvement. These findings showed that governance systems had not always identified, mitigated or resolved issues in a timely way.

Following our feedback, leaders responded proactively and implemented additional measures to strengthen oversight and monitoring. This demonstrated a willingness to learn and improve.

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

Feedback from healthcare professionals was consistently positive about the service's communication, responsiveness and commitment to collaborative working. Healthcare professionals told us staff listened to advice, acted on recommendations and maintained effective communication.

One healthcare professional told us, “They recognise that successful outcomes are achieved through partnership working and always ensure that the young person or adult remains at the centre of everything they do.”

People were encouraged to maintain links with family, friends and their communities. The service supported people to attend local events, volunteering opportunities, education and social activities. The provider also worked with local organisations and charities and promoted activities that helped challenge stigma associated with mental health needs.

Leaders maintained relationships with neighbours and local stakeholders and sought to address concerns when they arose. These partnerships helped support continuity of care, positive outcomes and community inclusion for people using the service.

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.

Leaders reviewed accidents, incidents, safeguarding concerns and quality assurance information and shared learning through team meetings, supervisions, huddles and daily handovers. Staff received regular training and opportunities to reflect on practice.

The provider demonstrated a willingness to learn from incidents and concerns. For example, following safeguarding concerns leaders undertook investigations, reviewed CCTV where appropriate, shared learning with staff and introduced additional training. We saw evidence that leaders responded to feedback from concerns that promoted the assessment process and made changes to strengthen systems and documentation.

There were examples of innovative approaches to promoting positive outcomes, including the use of roadmaps, life journals, Wellness Recovery Action Planning and structured approaches to reducing restrictions and increasing independence. These approaches had supported some people to make significant progress in their recovery journeys.

However, some audits and incident reviews had not always identified patterns or recording issues early enough. During our assessment we found areas where documentation and governance analysis required further strengthening. This showed that although learning systems were in place and generally effective, there remained opportunities to improve how learning was embedded and used to drive consistent improvement across the service.