Woodway 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 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.

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 did not have a clear shared vision or strategy. Although they understood the challenges and the needs of people and their communities, systems and processes did not always support effective oversight and risk management to ensure people always received safe care.

Some people told us the culture of the home meant staff did not always focus on their individual needs. Their preferred routines were not consistently followed and they sometimes experienced delays in receiving support.

However, staff described a positive and supportive culture within the home. One staff member told us they felt the culture was “quite good” and that everyone worked well together. The registered manager also described a strong team ethos, saying the service felt “like a big family,” with many long‑standing staff and a commitment to supporting one another. They explained that “Staff consistently pulled together during challenging times and were highly supportive of each other, which they felt was one of the team’s key strengths.”

The provider had 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.

However, whilst leaders were compassionate, they did not always have effective oversight of care delivery, treatment and support, which meant they were not consistently identifying or addressing shortfalls in people’s care and learning from incidents. 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.

Staff told us leaders were visible, approachable and led by example. One staff member explained that the registered manager would step in to support day‑to‑day tasks when needed, such as helping to monitor communal areas, and the deputy manager regularly provided hands‑on care at weekends. They said that if call bells were sounding, leaders would respond alongside the care team.

Another staff member told us there was a strong sense of teamwork, explaining that “everyone mixes in” and that staff socialised together outside of work. They said the registered manager also attended these events and invited staff, which made them feel valued and appreciated. They added that senior leaders, including directors, also took part.

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

Staff were aware of the term freedom to speak up and understood how to raise concerns. One staff member told us they knew how to report issues such as suspected abuse and felt confident doing so. They said they could speak to a senior member of staff, the registered manager, wider management or directors, and were also aware they could contact external bodies such as the local authority, the police or the Care Quality Commission. They told us they had completed in‑house training on whistleblowing, which helped them feel informed and able to speak up if needed.

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 felt they were treated fairly within the service. The registered manager explained that reasonable adjustments were made to support staff with disabilities or long‑term health conditions. They gave an example when a staff member had been absent for an extended period due to significant health issues and returned to work. They offer a phased return and reduced hours to support the staff member’s wellbeing.

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.

The registered manager did not always have effective oversight of the audits in place. Although systems and processes existed, they required improvement. For example, they had not identified the shortfalls and risks we found during this inspection in relation to the environment, medicines management, staff training and supplementary documentation, some of which had not been completed effectively.

The registered manager assured us that, following our feedback, they would be reviewing and strengthening their audit processes to ensure they were more robust and able to identify issues promptly.

The provider had a business continuity plan in place to guide the service in the event of emergencies or significant disruption, such as adverse weather or staffing shortages. A red, amber, green (RAG) rating system was also used to assess risk and identify vulnerability when unforeseen circumstances affected the service. This helped the provider prioritise people’s needs and maintain service delivery during periods of pressure.

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.

Professionals told us the service worked well with external partners and contributed to wider community learning. One professional shared, the provider engaged with external forums designed to share learning and support improvements in care. Another professional told us “Staff are proactive at seeking advice and guidance. I have no concerns with the staff, leaders or the service. It is clear that staff know their residents well and strive to achieve the best care for them.”

The provider did not always focus 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 did not always actively contribute to safe, effective practice and research.

While the provider had begun to learn from feedback and introduce changes, these improvements were not yet fully embedded or applied consistently across the service.

The registered manager told us the service was exploring new ways of working to support continuous improvement. They said they were looking into moving to an online medicines system and planned to access further training to make better use of their existing electronic care management system. This was intended to enhance oversight and support more efficient, accurate record‑keeping. The registered manager welcomed our feedback and had started to take action to address the issues identified during our inspection.