Woodrow Retirement 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

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 requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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

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.

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 told us the culture was supportive and open. One staff member said, “Everyone get’s on well and the residents are happy. It’s a good place to be.”

Leaders did not always have the skills, knowledge, or experience to lead effectively. The Registered Manager, who was also the Provider, had employed a manager to oversee the day to day running of the service. They had not implemented any formal governance process to ensure they retained full oversight of their legal responsibilities. Whilst improvements had been made to the governance of the service since our last inspection, we found areas of improvement were still required. People’s relatives told us senior staff were accessible and communication was good. One person’s relative told us, “I quite often meet the manager and there has been many opportunities to talk to them about mum when I visit.” Another relative said, “The general communication is very good with the manager.”

People did not always feel they could speak up and that their voice would be heard. Whilst people, their relatives and staff told us they felt comfortable raising any concerns, there were no formal systems in place to record concerns or evidence any action taken in response to people speaking up. The lack of formal systems meant we could not be assured any concerns were investigated, with lessons shared and acted on.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us they felt supported and felt it was a positive place to work. One staff member said, “It’s a lovely place to work, the staff are all lovely.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not always monitor information about risk, performance and outcomes. Following our last inspection, the provider completed an action plan detailing the action they would take. At this inspection, we found not all those actions had been completed. The providers policies did not support best practice. The provider did not have good systems to ensure oversight of staff training and had not identified some mandatory training was out of date. There were limited governance systems in place, and the provider had failed to identify health and safety risks. The provider did not complete any formal governance checks; however, staff told us they were actively involved in the day to day running of the service.

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.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. There were no systems in place to ensure staff were aware of innovation or best practice. The provider had limited engagement with external bodies or local networks.