Woodfield Care 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 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.

This service scored 57 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Improvements were required to the governance of the service to ensure it was effective in day-to-day quality assurance. Audit processes required strengthening to help the management team identify problems and the actions required. We looked at a range of the provider’s audits, and these did not always reflect our findings during this assessment; however, the registered manager and deputy manager were responsive to the concerns raised and acted promptly to implement more robust monitoring around medication, call bells and people’s weight management.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The registered manager was committed to delivering a good service; however, gaps in governance and risk oversight meant people could not always be assured the service was consistently well-led and lessons were used to drive improvements in care quality.

Some relatives mainly told us they were aware of the new registered manager but felt they were not very visible in the service yet. One relative told us, “I don’t know who the [registered] manager is. I knew the previous [registered] manager though. I generally speak to the seniors who I see regularly.”

Staff told us they knew who the new registered manager was and felt they could raise issues if needed but generally approached the deputy manager.

Staff felt morale had improved since the last assessment.

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

Staff had completed whistleblowing training and mainly told us they felt confident about speaking up and their voice would be heard, although some staff were unsure who to approach to raise concerns.

We saw evidence of whistleblowing posters around the service.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider worked to support diversity in their workforce. However, they did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The registered manager told us staff were offered reasonable adjustments to the work shifts but at present, no one has requested these.

Staff had completed training in equality, diversity and inclusion. However, further work was needed to develop the culture of the service to ensure staff views were listened to, valued and included in the development of the service. For example, recent changes within the services structure, staffing levels and new management had impacted on staff morale, and we saw no evidence of staff being supported through the changes. One staff member told us, “I think the problem is the managers change frequently.”

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.

Systems were in place to monitor the quality and safety of the service, including audits and oversight processes to review care and identify areas for improvement. However, some audits had not always identified issues found during the assessment, including gaps in medicines documentation, and peoples weight monitoring. This meant governance systems were not always fully effective in identifying and addressing risks, or in ensuring learning was consistently recognised and used to improve practice.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people.

They did not always share information and learning with partners or collaborate for improvement.

The provider needed to strengthen partnership and community working by improving routine communication, information sharing and joint learning with partner agencies

Statutory notifications were mostly being submitted as required to the Care Quality Commission, however some of these had been missed and were submitted to us at our request as part of the assessment.
We discussed this with the registered manager and retrospective notifications were made.

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.

There was a focus on learning and improvement within the home. Leaders were open to feedback during the inspection and demonstrated a willingness to engage with ongoing improvement and development.

Staff were involved in meetings which allowed the opportunity to share views and contribute to improvement. These arrangements supported the sustainability of the service and the provider’s ability to continue to improve.

While some changes were still in the early stages and not yet fully embedded into practice, there was evidence improvements were being implemented, moving forward.