Woburn House

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 inspection we rated this key question good. At this inspection, 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 service is in breach of the legal regulation of good governance. Audits and governance measures were not effective or robust enough to consistently identify where improvements at the service were needed.

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. The culture at the service was positive. Staff understood their main role was to support people to have the best experiences possible. People were happy and relaxed being supported by the staff team. Staff respected people’s home and were led by people as to how they wanted to be supported and how they wanted to spend their time. People were supported to take positive risks and follow their interests and pastimes if they chose to do so. People showed us how happy and relaxed they were in the way they interacted with us and staff supporting them. They comfortably asked staff for support and staff patiently helped them with what they needed. A relative told us, ‘‘[Family member] is happy and settled and the staff team are wonderful. That realty is all we could ask for.’’ Another relative said, ‘‘[Family member] used to be so upset all the time and would be angry with themselves or others a lot. This has gone down so much since they started using the service. It’s a good indicator for us of how kind and caring the staff team are.’’

Leaders did not always have the skills and knowledge to lead effectively. However, they led the service with integrity, openness and honesty. The management team were dedicated, kind and compassionate. However, they were not always fully capable in all areas of their responsibilities. For example, they did not report incidents to CQC in line with legislation or ensuring appropriate checks of staff suitability took place before they started in their job roles. Audits were not in place or were not effective in identifying where improvements could be made at the service. We discuss this further in the ‘governance, management and sustainability’ section of this report.

Staff told us the management team were approachable and included them in discussions about the service and how best to support people. They worked alongside the staff team and spent time with people. This helped them to understand the way staff supported people and identify any areas they could help with further. One person said, ‘‘Yes, I know [registered manager]’’ When we asked them if they knew who they were. A relative told us, ‘‘The [management team have high standards when it comes to who works for them. They know [family member] as well as the staff do and are always open and honest with us.’’

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There was a complaint and speaking up policy in place at the service. When people or relatives raised concerns, these were investigated and addressed promptly. Relatives told us they knew how to raise concerns and were confident these would be addressed. Staff told us they knew how to raise concerns and felt comfortable and confident in speaking up at the service. People were given easy to understand information about who they could speak with if they were worried about the service or wanted to talk about anything. They were also encouraged to feed back about the service in meetings with staff members. The management team kept a record of complaints to help inform learning and make sure issues raised were not repeated. A relative told us, ‘‘[Staff] are very responsive if you raise anything.’’

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 enjoyed working at the service and felt well supported by the management team. The provider supported their equality and wellbeing by offering preferred working patterns and discussing their job roles with them regularly. The providers recruitment process was fair and equitable.

The provider did not have clear responsibilities, roles and systems of accountability or good governance. Audits and governance measures at the service were not in place or were not effective in some areas of service provision. We were shown very few meaningful audits during our inspection, and it was unclear how the management team were monitoring the quality of the service effectively. For example, we were shown an overarching audit with a tick box as to whether people were receiving choices in their care and support or being supported to be independent which were all marked as ‘yes’. It was not clear how this had been established. It was not clear how people’s care records were being reviewed in a meaningful way to help ensure they were being supported to achieve their desired goals and outcomes. There were no service improvement plans in place based on findings from audits. Incidents were not always being monitored effectively or shared with partners such as the local authority or CQC. Audits of care plans had not picked up on the lack of detail in people’s care plans and risk assessments we found at this inspection. The management team’s response to our feedback was encouraging, however we could not be assured issues would have been picked up by governance measures in place at the service.

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. The management and staff team had good working relationships with partners such as health professionals and local authorities. Staff supported people to be a part of their community and follow their interests and past times. People went shopping and attended local establishments such as restaurants or social clubs and groups in the community. One person showed us how much they enjoyed their social club in the community relating to music and sang us a song they sang there. A relative told us, ‘‘[Family member] has a great social life. If you compare now to a couple of years ago the difference is quite staggering.’’

The provider focused on continuous learning, innovation and improvement; however, audits were not always effective in supporting this. Audits were not being completed in some areas or were not effective making it harder to identify and drive meaningful improvements at the service. Care plan and daily record reviews did not notice where improvement was needed relating to inconsistencies in people’s care plans and risk assessments.

The management team acted based on our feedback. They were dedicated to improving the service and had worked hard to improve the lives of people using the service. Many people were living with complex support needs but had been successfully supported to live in the community in their own homes. Staff told us they were involved in discussions and meeting about the service and their feedback about how to improve the service was listened to and taken seriously. People and relatives were happy with their/ their family member’s support and relatives told us they felt the service was good. A relative told us, ‘‘Nothing is too much for [staff] and I know the service always try their very best under what can be difficult circumstances to support [family member] to have the best life they can.’’