Woodstock Nursing Home

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• 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 found improvements had been made to the provider’s quality monitoring systems and processes. A new senior leadership team had been recently formed and they were providing the service with the support it needed to make improvements. At the time of the assessment more time was needed to demonstrate that this support would achieve the necessary improvements needed to the service. It had also been recognised by the senior leadership team that more support and guidance was needed for the registered manager, and this was being provided. At the time of the assessment staff were aware of the challenges facing the registered manager, but they did not always feel the registered manager’s approach was supporting effective teamworking.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

At the time of the assessment, we received mixed feedback from staff. Some staff told us they felt able to challenge decisions made by the registered manager and others felt they could not speak up. A member of staff told us there had been several changes with senior staff within the care team, which had not helped staff morale or helped with the implementation and embedding of some needed improvements. Another member of staff was positive about the support the provider’s new senior leadership team were providing. This had included more support for the registered manager plus investment into new electronic systems, which they told us were making the provider’s recording and reporting requirements easier for staff to complete. They said, “[Registered manager] is getting a lot more direction from [regional manager] which is what she needs. There are different audits which are more regular and in depth and there are plans for redecorating and for new furniture.” The regional manager told us the senior leadership team worked well together and support was being provided to the service so improvements could be made. The provider’s quality assurance manager told us the medicine audits would be reviewed following the identification of shortfalls during the assessment. This was to ensure these captured the right information to be able to identify and action any shortfalls.

We found the provider had improved audits and had introduced a new tool for identifying new and emerging risks across their services. The provider had continued with an annual schedule of audits which were completed by staff in the service; some of these were now designed to capture more detail. We reviewed audits for medicines, infection, control and prevention, call bell usage, staff recruitment files and care records. We reviewed the clinical risk reports which were used to monitor people's clinical risks and the actions taken to reduce these. Clinical risk meetings had continued to take place between the nurses and the registered manager which helped to inform the regular report the registered manager submitted for the provider. Actions from audits were added to the service’s performance improvement plan. This was managed by the registered manager and performance against this was monitored by the regional manager and the provider’s quality team, to ensure actions for improvement were completed. The regional manager and registered manager met regularly for support and performance related meetings. The provider was kept informed of the service’s performance through reports and meetings with the senior leadership team who visited the service regularly. The new early warning risk system report was also designed to give the provider’s senior leadership team better information about new emerging risk, across all their services, so they could more effectively focus their time and support where it was needed. The team were due to discuss the effectiveness of the report (so far) in their next senior leadership meeting. It was hoped this report would evolve as they learnt more about what they needed from it. As part of the provider’s investigation into the medicine shortfalls the medicine audits were to be reviewed to ensure they captured the information the provider needed to assure themselves medicines were being managed safely and in line with their policies.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.