Woodland 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 Outstanding. At this assessment the rating has changed to Inadequate.

This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to the governance at the service.

This service scored 32 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The culture of the service did not reflect person-centred values. Staff frequently focused on supervision, risk management and tasks rather than enabling meaningful lives. References to the area where the home is based as a "compound" reflected an institutional culture.

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

We identified breaches of the legal regulations and concerns in the areas of safeguarding, safe care, person centred care, dignity and governance. Leaders had not independently identified and acted on these concerns prior to our assessment. Processes were not implemented to help make sure the service was led in an effective manner by staff who were capable in their job roles. The provider could not be confident the processes they had in place for monitoring and improving the quality of the service were used effectively. We identified multiple areas of concern during this assessment. These had not been identified by the management and leadership within the service.

However, we received positive feedback from staff about the leadership of the service. Staff told us the manager was approachable and they felt listened to.

People did not feel they could speak up and that their voice would be heard.

We could not be assured people, and staff always had the freedom to speak up. Safeguarding concerns and incidents were not always appropriately reported by staff or identified by the provider. We could not be assured people, and their relatives would be informed of these concerns promptly and would be given an apology where required.
 

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.

Policies and procedures were in place for workforce equality, diversity and inclusion to enable a more equitable and inclusive organisation. However, these had not been fully implemented in practice. Limited evidence was available regarding how leaders promoted equality, diversity and inclusion within the workforce. Some staff reported divisions within the staff team.
 

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had failed to ensure governance processes were effective. The systems in place had not resulted in the service being maintained to a safe and appropriate standard. Areas for improvement were not identified, and improvements were not made when required. One person’s relative said, “I wouldn't recommend the home at present, although I'm aware that some remedial work has taken place.”

Audits and oversight activities failed to identify concerns relating to safeguarding, dignity, environmental safety, communication support, restrictive practice and person-centred care. Multiple incident records contained identical management reviews regardless of the nature of the incident. These reviews failed to analyse triggers, quality of staff responses or opportunities for learning. A service audit had already identified that incident records lacked meaningful information about how people felt following incidents. Despite this, the same issue continued and no improvement had occurred by the time of the assessment.

Improvements were initiated during the inspection. However, this assessment identified that systems of oversight were not being implemented effectively and there were multiple concerns within the service. These had not been identified or acted upon in a timely manner. Failure to maintain oversight of quality monitoring processes placed people at risk of receiving poor care.
 

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.

Leaders had not consistently worked with partners and community organisations to broaden opportunities available to people. Community engagement was limited and positive outcomes were limited by the culture of the service.
 

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

At the time of assessment, we found multiple areas of concern in the service that had either not been identified or addressed. The provider had not demonstrated effective learning and improvement systems. Repeated concerns remained unaddressed and quality assurance processes failed to identify deterioration within the service.

Processes were not implemented effectively to enable a consistently good service to be provided to people and improvements had not been made where required. Audits were not effective in identifying where improvements needed to be made and the service was not meeting the fundamental standards we expect from care services.

Although the provider took action to make improvements in response to our feedback following this assessment, we cannot be assured these improvements will be sustained and embedded.