Woodcote Hall

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 questioninadequate.At thisassessmentthe rating haschanged to 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 75 (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. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff and leaders had created a warm and welcoming atmosphere in the home. The focus was on the needs and well-being of people and of promoting a supportive culture. There was a shared vision in place for the home which was discussed at staff meetings and supervisions. This included values such as compassion, respect, integrity and community. Not all staff were aware of this; however, all were able to talk about Woodcote Hall being people’s home and how they wanted to provide a caring home where everyone felt like family, including relatives. The registered manager told us they would revisit the shared vision with staff in meetings to ensure all staff understood this.

The service had recently achieved the NHS Care to Smile award. Care to Smile is an NHS programme designed to improve the oral health of residents in residential and nursing care homes and provides care homes with tailored resources and ongoing support. The registered manager told us they were proud of the award, which had been achieved through the dedication of 1 staff member who was the oral health lead. Now they had achieved the award, staff would be trained to further enhance their knowledge and skills to deliver effective oral care to people.

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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

There was capable, visible and clear management at Woodcote Hall who demonstrated a passion for the service and for providing high quality care. Staff knew who to go to if they needed support for themselves or for meeting people’s care needs. They told us the registered manager was approachable and easy to talk with. When the registered manager had made improvements to the service, staff told us they were included in these and asked to contribute. One staff member said, “[Registered manager’s name] is supportive and friendly. I see them around the home throughout the day, and they will talk with the residents and us (staff).”

The registered manager was knowledgeable and understood the priorities for the service. This included their Dementia Strategy which together with the area manager they kept on target and updated with achievements. They were supported by the provider to develop in their role through training, learning and peer support.

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

People and relatives felt able to speak up and report concerns and were encouraged to discuss how they felt about the care they received. They were also asked about their care by managers, including senior managers when audits of the service were completed.

Staff understood about speaking up. The provider had a policy in place which supported staff in speaking up about unsafe care, this is also known as whistleblowing. One staff member said, “I know I can speak my mind and not be judged by managers.”

The provider strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them.

All staff we spoke with told us they were valued, treated fairly and felt supported in their roles. They said the registered manager was fair with working patterns and were flexible with rotas if staff needed time off or needed to work specific shifts.

The provider employed staff from overseas and actively promoted cultural inclusion. Staff organised events within the home to celebrate and respect the cultural backgrounds of their colleagues, which fostered a sense of belonging and community. The area manager told us, “We respect our staff’s culture and celebrate it.” People told us of recent celebrations which they had enjoyed being part of. One staff member said, “We celebrate our traditions and festival. The whole home is involved, managers are supportive of this, and the residents have embraced it. They all dance and eat with us.” Another staff member said, “Having everyone celebrating with us has made it more comfortable and homely here.”

As a result of feedback from employed overseas staff, the registered manager had identified an overseas champion to help support staff in their new role and whilst learning a new culture. The overseas champion supported by the provider’s recruitment team helped to guide, advise and support staff who were new to the UK. Meetings were held at the home between the provider’s recruitment team, the overseas champion and international staff to discuss and support with any queries or concerns. They also ensured staff were being treated well.

We identified some records and medicine audit systems needed improvement. This included contradictory information in 1 person’s care plan about what type of catheter they had. Their care plan did not state how often their catheter bag should be checked and emptied. We also identified the concerns with the management of people’s medicine. These concerns were addressed promptly, and we saw evidence to confirm this. Medication audits were completed monthly where each month 3 people had their medicines checked. We noted not all their medicines were routinely checked. One person was prescribed 14 different medicines but only 5 were checked as part of the audit. This was discussed with the registered manager who agreed all medicines for a person should be audited and they would amend this.

The provider had clear governance, management and accountability arrangements in place. Their quality management system detailed the responsibilities of all staff across the organisation to continuously improve the quality of service delivery and outcomes. The registered manager was accountable to the provider and had responsibility to complete quality reports about key areas of the service. The registered manager kept their service improvement plan continuously updated with any actions identified through audits, quality visits and feedback.

The registered manager demonstrated a culture of learning across the service and had improved the governance systems. They used feedback and current best practice to effectively monitor and improve experiences for people. The registered manager understood their regulatory responsibilities to remain registered with us. They submitted statutory notifications to us as required. Statutory notifications ensure we are aware of important events and incidents that affect services or the people who use them. Providers have a statutory responsibility to submit these, and they provide us with crucial information to monitor the quality and safety of services.

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.

Staff and leaders worked in partnership with health and social care professionals to achieve good outcomes for people. Every professional we contacted gave positive feedback about the staff and the service provided. They all told us staff worked closely with them to ensure better outcomes for people. One healthcare professional told us, “They [staff] are always keen to be involved in discussions regarding ongoing care, which supports shared decision making and promotes positive outcomes for residents. Staff also communicate effectively and share relevant information promptly, particularly when there are changes in a resident's condition, such as a deteriorating wound or deterioration in an end-of-life patient. This joined-up approach supports positive outcomes and promotes resident well-being.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They actively contributed to safe, effective practice and research.

The registered manager demonstrated a strong commitment to continuous learning and service improvement. Since being in post, they had made significant improvements and told us, “I wanted to give staff guidance and confidence, to help train staff to make them feel comfortable and confident in their roles.” Some staff were designated ‘champions’ in their area of expertise such as oral health, moving and handling and mental health. Some staff had completed advanced training to increase their competence, such as the Care Home Assistant Practitioner (CHAP) courses.

The registered manager analysed feedback from quality surveys and used this to help identify areas for improvement. They also analysed current survey results in relation to past data to pinpoint improvements and detect any patterns over time.

Staff were also supported to improve by the relationships they had with healthcare professionals. Specific staff had been trained by their Community Nurse Team to administer a specific medicine and to carry out checks to help manage people’s diabetes. Staff had also been trained to apply basic dressings. This supported the Community Nurse Team to manage their resources and gave staff developmental opportunities.

The service had taken part in quality improvement research projects, which included an Integrated Care Board (ICB) funded dementia awareness training. The project aimed to improve the care and support given to residents living with dementia by adult social care providers. In return the service provided data to evidence if the project was effective and useful. These projects helped to embed good evidenced-based practice throughout the service.