Woodroffe Benton House

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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

The overall rating for this key question is requires improvement. We identified areas needing improvement and a breach of regulation in respect of good governance. Quality assurance systems were not always in place to highlight where improvements were needed. There was a lack of oversight in respect of incidents, accidents and safeguarding which meant concerns were not always escalated to the local authorities appropriately and there were missed opportunities for wider learning to take place. The management team did not always create a culture to support the delivery of high-quality care. Where concerns were identified with medicine management, issues had not been fully addressed and managed. Audits of people’s care records were not in place leading to inaccuracies and limited information. The registered manager was aware of this and had started to update people’s care records. Some quality assurance audits worked well, for example, IPC, kitchen and laundry audits were completed; shortfalls identified were addressed. Environmental checks picked up areas needing improvements and were added to a service improvement plan. There were high levels of staff performance monitoring within the service. Some staff told us members of the management team did not always encourage growth but felt reprimanded instead. Some staff were no longer working within the service which, with the absence of clear care records meant new or agency staff were not always familiar with people’s needs. Staff had contact details of all managers including the senior management team to enable them to speak up. If staff felt unable to speak up, they had access to a whistle-blowing policy for further direction. People told us the service was well-led although they did not know who the registered manager was. People were not always involved in their care and running of the service. A quality assurance tool to gain people’s feedback about the service was in place, however, it was not fully utilised.

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 registered manager oversaw Woodroffe Benton House and another of the provider’s services within the same grounds, they were supported by a deputy manager who was new to both services. The registered manager had been in post since January 2024. and told us of quality assurance processes they had planned to embed, however, due to a higher turnover of deputy managers, they had not had a chance to implement their proposals. Some care staff told us they had not been offered to attend staff meetings and they felt communication required some improvements. A staff member said, “We had a little meeting the other day but nothing for ages. Not since [registered manager] has been the manager. Communication here is quite poor. From management and seniors, everybody.”

Meetings were held between heads of departments, minutes showed various topics were discussed, such as, catering and health and safety. It was clear which person was responsible for areas of improvements and the expected timescales. We viewed minutes of a senior care meeting; the meeting had been held between our visits. They included shortfalls identified by the management team from walk rounds and audits. Some staff had requested training on the electronic care planning system during the meeting, staff told us the training was being arranged based on this feedback.

The registered manager told us of the many years they had worked in care management, they were supported by a deputy manager who was new to the service. The nominated individual regularly visited the service to support the staff and management. Staff spoke positively about the management team. Comments included, “[Registered manager] is wonderful.” And, “They are good people, the higher people, (members of the board), they are wonderful people with a big heart. They listen and the understand people, they have humanity, I love them and respect them from all my heart.”

Most people we spoke with told us they did not know who the registered manager was, however, they felt the service was well run and would speak with staff if they had any concerns. Their comments included, “I have never seen the manager, but I think it is well run because everything happens when it is supposed to and the staff are always very calm and although busy.” And, “I know there is one (a manager) and I think it is well run, everything happens when it should and the staff are always there, although sometimes they change over in the night which is odd.” The management team recognised achievements and improvements in staff, for example, there was an employee of the month scheme to encourage staff performance.

Staff told us they were comfortable to speak up and gave examples when they would. A staff member told us, “I would feel comfortable to speak up, it would be to any of them (management). There is a way of saying things to people without being rude. I haven't recently needed to speak up. If I see things I don’t like I tell the carers even though it's not my place, for example, when they (people) are not moved quick enough.”

Systems and processes were in place to ensure everyone had the freedom to speak up. The whistleblowing policy was available should staff wish to refer to it. The registered manager, nominated individual and members of the board welcomed staff to contact them anytime. The provider’s whistle-blowing policy directed staff to who they could contact should they need to speak up. The policy included a flow chart for staff to follow so aid their understanding of protected disclosures.

Some staff were recruited from overseas, we discussed with the registered manager about how overseas staff were supported with living life in the UK. The registered manager told us about the training courses staff had attended, however, besides an English language course, there was no additional support offered to staff on how cultures may differ from their home counties to the UK.

A member of the management team shared records of staff who were identified as needing additional support, the records showed conversations where some staff had requested additional training, however, this was not always offered and disciplinaries commenced. The senior management team told us they had recently distributed employee satisfaction surveys and they would address any concerns that were raised. Staff had access to a mobile phone app which contained details of all staff members including contact details for the senior management team. The management team communicated with staff through the mobile phone app, communications could be two-way. The app gave managers the opportunity to advise staff of changes in the service, also information about how to stay well during adverse weather and local concerns, such as, protests and events which could affect staff safety.

The registered manager shared with us that when they started there were no quality assurance systems in place. The registered manager had designed their own audits and systems which were intended to provide oversight of the service, these systems were yet to be utilised and embedded. The registered manager told us, “It’s difficult to be on top of the 2 homes.” The registered manager was trying to establish a new deputy team, however, there had been some challenges as some candidates were not suitable.

The registered manager did not always complete their regulatory responsibilities. Safeguarding concerns and incidents had not always been investigated and escalated to the local authority. Statutory notifications to CQC had not always been submitted, these were under the previous registered manager, however, the provider’s systems had not identified these omissions. Senior management and some delegated staff conducted audits and devised actions plans based on their findings. Most audits were effective; however, not all processes had commenced or been embedded. We identified areas of concern. For example, people’s care plans and risk assessments had not been kept up to date and were not accurate, there was no mechanism or process to ensure people’s care records were relevant and fit for purpose. The registered manager had designed a quality form with the intention to be completed monthly by representatives from all departments. This was to gather direct feedback from people, update care records, check whether the person was satisfied with their meals and bedroom maintenance. There was an opportunity for people to provide general feedback to the registered manager. We saw examples where the form had been effective when completed by care, maintenance and housekeeping staff, however, the management section had not been completed.

People were able to go out with their loved ones and invite their friends and family into the service, this included meeting them at the coffee shop which was situated in the grounds. People told us they enjoyed going to the on-site café but wanted more outings. A person said, “[Family members] come twice a week and take me out which I look forward to, we used to have minibus outings before the pandemic but not now.”

Staff and managers missed opportunities to obtain people’s feedback about spiritual, cultural and community involvement. However, health and social care input was sought when required. The registered manager told us about how they engaged with professionals to support good outcomes for people. For example, a person living with advanced dementia had been discharged from the Dementia and Older People’s Mental Health Community Team as staff had followed recommendations and the person was responding well to their approach. The registered manager shared plans about a local nursery coming to visiting people living in the service.

Visiting health and social care professionals provided feedback about the management team and told us of positive changes they were aware of. Their comments included, “I have a good working relationship with both [deputy manager] and [registered manager]. They value my input and are committed to improve care.” And, “Clearly there has been a lot of change at the care home and management seem very engaged in trying to implement better procedures and improve the quality of the care. We have had several very useful meetings with the management team and wider organisations. However, I am very concerned about the quality of patient care that is being delivered whilst new staff and procedures are being implemented.”

There were limited chances for people to contribute to the running of the service to include partnership and communities. People told us they had not been offered to attend meetings. Comments included, “There used to be meetings though I haven’t heard of any recently, nothing ever changed as a result.” And, “I don’t think we are having them (meetings) at the moment.” People told us they were not given feedback questionnaires to complete, one person said, “I haven’t seen a survey.” When asked if people were able voice their opinions and give ideas and suggestions, all people we spoke with said they were not asked. Outside agencies and partners visited the service, their advice and findings were addressed. The management team deployed appropriate staff to rectify findings. For example, West Sussex Fire and Rescue Service had identified areas of improvements required, works had been completed.

The registered manager and senior management team told us of improvements they planned to make to the service, this included facilities such as, a cinema and a spa. However, processes did not always identify and address improvement actions required within the service. The registered manager provided examples of where other lessons had been shared, for example, in relation to medicine management, however, these had not been learned from and errors continued.

There was a lack of processes in place to enable learning and continual improvements. Audits were not always conducted or where areas had been identified for improvements they had not always been addressed and monitored. Some processes were in place to monitor and improve the quality of the service. Where shortfalls were identified, the management team had developed a comprehensive service improvement plan. The plan was a live document and was updated where tasks were completed or where additional areas had been identified for upgrades and improvement. The registered manager attended managers meetings with other managers of the provider’s services, they shared and learned lessons, mutual support and advice.