Woodlands Lodge Care 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 identified one breach of regulation. During our assessment of this key question, we found concerns around the governance and leadership of the service which resulted in a breach of Regulation 17. You can find more details of our concerns in the evidence category findings below. The provider did not have sufficient oversight to monitor the quality and safety of the service and to ensure there was effective leadership in place. The service did not have an effective quality assurance system to ensure people received safe care which was person-centred.

This service scored 25 (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 had been changes recently within the management of the service. Staff recognised that there was a lack of leadership in the service and told us this had impacted on both their morale and the service's performance.

Leadership at the service had failed to ensure there was a positive culture at the service that was open and person-centred. The service was in the process of recruiting new people into the management structure after a period of managerial instability, any improvements from this will take time to embed.

There was not an inclusive culture at the service. Staff and relatives raised concerns about the leadership of the service.The service did not have a registered manager and was in the process of recruiting into this role. The interim management team said the governance processes had not been followed as intended as a result.

The provider did not have sufficient oversight to ensure the service had a positive culture that was person-centred, open, inclusive, and empowering and there was effective leadership in place.

Staff knew about whistleblowing procedures. Staff told us they had been raising concerns but did not feel listened to.

The provider had a complaints procedure however there was no records of comments or complaints or evidence of meetings taking place to gather peoples views and feedback about the service. The processes in place at the service had failed to ensure that staff feedback was used effectively or that action was taken to ensure staff felt valued.

We received mixed feedback from staff, some said they worked well as a team others said they did not and did not feel listened to and were frustrated with changes and high agency use.

There was no evidence to show equality and diversity was promoted, and the causes of any workforce inequality identified.The processes in place to ensure staff felt empowered and were confident their concerns and ideas resulted in positive change required improvement.

The interim management team told us they could not provide any audits due to the change of manager. They were in the process of transferring care plans on to a electronic system.The management team acknowledged this required further work.

The provider failed to implement and operate effective risk management systems and to assess, monitor, and mitigate risks to people. We found various shortfalls, for example, medicines management, infection control, staffing levels and assessing and monitoring peoples planned care and risk assessments. There was a lack of effective leadership in place to ensure that governance and auditing processes were completed accurately. The audits that were in place at the service had failed to identify concerns at the service.

People’s feedback about their involvement with care planning was inconsistent, some people told us they did not feel their feedback was listened to.

The management team informed us there were a lot of issues to address and were aware of the concerns. The management team had undergone a change and the service is currently being managed by a interim management team. The current management team acknowledged they needed to improve outcomes for people. Staff had found the changes in management unsettling and they felt the service lacked clear guidance and direction. They also felt they were not included or listened to in any descisions about the future of the service.

The provider had agreed with the local authority to stop admitting people to the home until improvements had been made. Professionals who visit the service told us that information was not always shared consistently or in a timely manner. Some professionals raised issues about difficulties with contacting the service, staff following through on actions requested by health professionals and about the availability of staff on site to support with professional visits. Some issues were also raised in regard to the accuracy of documented information in peoples care plans.

Processes in place at the service had failed to ensure that information recorded about people was always up to date, accurate or sufficiently detailed. This meant that when information was shared about people between services the quality of this information could not be guaranteed.

The management team informed us there were a lot of issues to address and were aware of the concerns. The management team had undergone a change and the service is currently being managed by an interim management team The current management team acknowledged they needed to improve outcomes for people. Staff had found this unsettling and left them without clear guidance and direction. Comments from staff included,"There is no specific job roles for people above us, we are not even sure who the manager is or who is doing what." Another said, "Theres no one I can go to if I have any concerns, if I go to [manager] they wouldnt do anything about what I say."

The home had deteriorated since our last inspection. We found people were not always supported to have maximum choice and control of their lives because choice was not always actively promoted. Audits and systems had failed to identify and address issues at the service including insufficient levels of staff training, issues with the management of medicines, insufficient staffing levels and issues with infection prevention and control.The quality of people’s care records and risk management required improvement. The provider had not ensured that safety events were investigated and reported thoroughly, and lessons were learned to continually identify and embed good practices.