Woodleigh Rest 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

This key question has been rated requires improvement. We reviewed 7 quality statements for this key question. There were quality assurance processes and procedures in place however we found these had not always been effective in identifying and addressing issues with care records and medicines. We identified a breach of the legal regulations.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff feedback about the culture and shared direction of the service was positive. Staff felt involved and engaged in the day to day running of the service. Several staff highlighted the improvements which had been made and their enhanced teamwork had positively impacted on people's experiences. Staff told us they embedded the values of the home through discussions and as a structured part of 1-to-1 supervision with staff. The registered manager also said there had been improvements in the culture of the home.

Processes were in place to ensure the team had a shared direction and culture. There were regular team meetings which were well attended, and the notes were shared with staff who were not able to attend. Staff had regular recorded 1 to 1 supervision and an annual appraisal. This included a discussion about the home's values and how staff were demonstrating this.

Staff spoke very positively about the registered manager. They said the registered manager was supportive and approachable. They said they had been influential in driving improvements in the care and support people received. They also described good communication and teamwork. 1 staff member described the registered manager as "A breath of fresh air."

The registered manager and provider were receptive to feedback throughout the assessment process and took action where we highlighted shortfalls. For example, where there were shortfalls in care records, they updated them promptly and provided evidence to the assessment team. There were processes in place for the registered manager to communicate with people, relatives and staff. There was inconsistency in the quality of records, how and when information was recorded and the accuracy of information recorded. Some records relating to complaints and meeting minutes were not always completed objectively. We discussed this with the provider who confirmed they would address this. The registered manager demonstrated they were open and compassionate throughout the assessment process, and this was corroborated by staff and stakeholders.

Staff were aware of the process to raise concerns and felt empowered to speak openly. 1 staff member said, "Yes, all of the staff of our home is actively aware of the Whistleblowing Policy to make sure that we are providing our best service." All the staff we spoke with told us the registered manager was accessible and approachable. The provider told us they felt assured staff felt comfortable to raise concerns and they had an 'open door policy."

The provider had an up to date Whistle blowing Policy which signposted staff on how to raise concerns and seek advice and support externally if required. Regular staff meetings took place and there was evidence of good attendance and staff involvement.

The provider had a supportive culture where staff mattered. They employed a diverse staff team. Staff told us they felt listened to and were supported in their role.

The provider had processes in place to recruit, induct and provide training and supervision equitably. The provider employed a diverse staff team.

Staff thought the home was well managed and there had been improvements to how people's health and well-being was monitored. 1 staff member said, "I will say it confidently, our house is well-run." The provider told us they had improved the auditing process but acknowledged this required further development and embedding to ensure improvements were sustained.

Audits to monitor the quality of the service were regularly completed and action plans created and reviewed. However, they had not identified multiple shortfalls we identified as part of the assessment. We found no evidence that people had been harmed. However, systems were either not in place or robust enough to demonstrate good governance. This placed people at risk of harm. This was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. There had been improvements to the provider's auditing processes. For example, people's weights were clearly monitored, and action taken when required. The registered manager completed an annual care plan audit, but this lacked detail. Care plans were reviewed monthly but were inconsistent with gaps in records. We did not identify serious concerns in relation to the impact on people.

People and relatives told us the provider worked well with other agencies, including the GP and other health professionals.

The provider told us and was able to demonstrate they worked in close partnership with other agencies. Staff worked directly with the pharmacist, GP and district nurse's and the registered manager had recently introduced weekly meetings with the district nurse team to improve effective communication. They also worked with other health professionals including speech and language and occupational therapy teams. The activity coordinator was also part of a group focussed on developing meaningful activities and opportunities for people. The provider had enlisted the support of an external consultant to review the quality and safety of the service provided. There was some evidence of working as part of the community including the local church however, this was limited.

Feedback from partners was positive. 1 social care professional told us the registered manager was, "Always keen to learn and take on board any suggestions." They also told us they had received positive feedback from people, relatives and other professionals about improvements at the service.

The provider had clear and effective systems and processes in place which demonstrated effective partnership working within the service's staff team, as well as with external professionals and partners. There was evidence in care records of professional visits including dentists, opticians, diabetic clinics, specialists in hospitals, continence service and social workers. Where people had conditions on their DoLS there was evidence to suggest this had been complied with and again demonstrated effective partnership working with professionals to meet these requirements.

The staff told us they had seen widescale improvements across the home which had resulted in improvements to the quality of the care people received and teamwork and morale. 1 staff member said, "We do things right, everything is good. You can ask [name of registered manager] anything and [they] are on it straight away." The provider told us they had made improvements and were committed to further developments. The changes they had made required further embedding to ensure improvements were sustained.

There had been improvements to auditing processes but further improvements were required to ensure these were embedded and areas where we found shortfalls were developed fully. There had been recent changes to how staff monitored communal areas which had led to a reduction in the number of falls people experienced. The registered manager was being supported to undertake a management qualification. The home had a Business Plan and Service Improvement Plan. Actions identified from these were monitored. There was an ongoing refurbishment plan in place. The provider shared learning with their other home in order to improve practice. However, we found examples where action had not been taken when events had occurred which meant lessons had not always been learned.