Woodford 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

We assessed all the quality statements in the key question of well led. We found some improvements had been made, however, there continued to be shortfalls in the oversight of the service. Shortfalls had not always been identified. When shortfalls had been identified, action had not always been taken quickly to rectify them and keep people as safe as possible. Staff understood their roles and responsibilities but had not always followed processes to make sure they executed their role. Staff told us there was a positive culture within the service and they felt supported. Staff attended regular meetings and thought they worked well as a team. The management team displayed information about how to raise complaints and concerns. The service worked with other agencies to keep up with changes in guidelines and practice.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us there was a positive culture which they said the registered manager had developed over the last 12 months. They said the team worked well together and all had the same goal, to provide good care and create a service where people were happy. “I am very happy here, (the registered manager) is a very supportive manager and really approachable. I have seen improvements, it was quite chaotic at one time but now more relaxed and staff are happy”.

Staff attended regular team meetings and had regular supervision with their line manager where they had the opportunity to share ideas and be kept up to date with changes. The provider had an in-house trainer so staff had face to face training for their introduction to the service and for some areas that needed practical guidance. This complimented online training.

Staff were positive about the registered manager, “You can’t get a better manager than (the registered manager), she is fantastic. I wouldn’t still be working here if it wasn’t for her”. “I feel well supported and I think the service is well managed. (The registered manager) is very approachable, I would have no problem going to her with anything. She is often out chatting with people and staff”.

The provider had a quality compliance team who monitored the delivery of care and support and created action plans where improvements were needed. They were able to offer support and advice with a view to continuous improvement. Provider led improvements could be cascaded through this team. However, this process and support had not always led to improvements and there still continued to be some shortfalls.

Staff told us they were confident any concerns they raised would be dealt with as this had been their experience. Staff said the registered manager was approachable and listened, to either work related concerns or personal issues. “I am very confident the seniors and the manager would act if I took concerns to them. The manager has acted whenever I have raised an issue with her”.

Posters with how to raise concerns were displayed on notice boards that people, relatives or staff could access. Staff attended regular team meetings and had regular supervision with their line manager where they had the opportunity to share ideas and be kept up to date with changes the provider planned. The provider had an in-house trainer so staff had face to face training for their introduction to the service and for some areas that needed practical guidance. This complimented online training.

Staff spoke positively about their experiences at work. They told us they were treated fairly by the registered manager. As a result of the registered manager’s approach, staff felt they worked well as a team and were treated equally. “Coming to work at Woodford is best thing that happened to me as I love it. We all work really well together as a team and that is mainly because of (the registered manager). She has supported me in many ways. I love coming to work and see myself here for a long time”.

The service is geographically placed in a multi-cultural area and the workforce reflected this. Recruitment processes had not disadvantaged different groups. The provider had policies in place to guide staff to make sure equality and diversity were considered in all aspects of their work.

The registered manager told us they were well supported by a quality compliance team and a clinical lead who supported herself and the registered nurses working in the service. However, we found shortfalls in care plans and medicines management which had not been addressed.

The provider had an improved auditing and monitoring process where issues were being found and action taken to improve. However, action plans had been developed but these had not always been signed as completed. Some shortfalls had not been identified, as reported in Safe. The concerns we found around safe recruitment and medicines had not been previously identified. The issues we found around individual risk had been identified during an audit on 3 June 2024 but crucial risk assessments for known identified risks had not been completed until the day of the assessment site visit 3 days later. The audit also identified missing risk assessments for another person, who was admitted into the service on 17 May 2024. These included an identified risk of choking and a high risk of developing pressure ulcers. The risk assessments were completed 19 days later. However, they had not been in place since the person was admitted and this had not been identified sooner, placing the person at risk.

People were referred to the appropriate agencies to enhance their care and make sure they were getting the care and treatment they needed. People and their relatives told us they had seen healthcare professionals and other agencies when they needed them. Independent advocates were contacted when people did not have family or friends who could help them to make choices and decisions.

The provider told us they attend local providers forum to share ideas and pick up new areas of good practice.

Health and social care professionals told us the service had engaged with them and taken advice and guidance when it was given.

Managers engaged in external training and subscribed to national agencies and journals to keep up with best practice.

Staff told us they were encouraged to share ideas by the registered manager. They said they were listened to if they suggested different ways of working within the service. However, there was little evidence the ideas and comments had been acted on, we continued to find shortfalls in areas of the service.

There were processes in place but these had not always been effective in making improvements to the quality of the service. Staff meetings, supervision and surveys were used as an opportunity to share ideas and feed back concerns. The notes of staff and nurses meetings showed that the registered manager used the opportunity to promote good person centred care and good culture, giving examples and raising when they had observed issues. Such as care plans not always being up to date or reflect people’s current needs. The registered manager included an action plan following nurses meetings so the areas discussed were shared as action points. However, this shortfall was still found during the assessment. The registered manager had evidenced where they had identified lessons had been learnt from incidents or complaints and concerns, what action they had taken to share this with staff.