Woodbury 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 a limited number of quality statements in the well-led key question and found areas of concern. The scores for these areas have been combined with scores based on the rating from the last inspection which was requires improvement. We identified a breach of the regulation in relation to good governance. The service did not ensure systems or processes were established and operated effectively to ensure compliance, assess, monitor and improve the quality and safety of the services provided. Systems were not in place to manage safeguarding concerns which were incomplete and not effective to ensure people were protected from abuse. Some audits were not completed fully. The incident report including actions and lessons shared, did not always show the lessons learnt specific to the person and that incident. The complaints log did not detail the complaints, nor the actions taken. It was unclear how internal audit documents linked together to inform effective oversight and action taken.

This service scored 43 (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.

We identified the service did not ensure systems or processes were established and operated effectively to ensure compliance, assess, monitor and improve the quality and safety of the services provided. Staff told us the registered manager and other senior staff listened to them. We were also told there were audits, care plan audits and all people’s care plans were reviewed every month. Leaders told us the provider had a governance system in place and, “When utilised fully it keeps a care home on track in respect of governance.” Leaders also told us, “It is the Home Managers responsibility to ensure that evidence is compiled and stored in this system to manage and deliver good quality, sustainable care, treatment and support.”

Systems and processes were not operated effectively to assess, monitor and improve the quality and safety of the service provided to people. Some audits and checks were not completed fully, which included the daily mattress checks, the monthly mattress audits and the pressure relieving cushion audit. It was difficult to analyse the service’s Provider Validation Review, and what actions were taken as a result of issues being identified. For example, it was identified the home manager’s accident and incident analysis was not completed for the review dated 29 August 2024. Issues identified in the previous medication audit created 6 August 2024 were still pending on 29 September 2024 and it was not clear why this issue was not rectified. We identified call bell monitoring records were incomplete and did not always document the actions taken as a result of the call bell being activated. During the site visit people’s call bells were being activated, one of which was activated very frequently. However, call bell monitoring records submitted following our site visit did not evidence any activated bells on the assessment day. There was insufficient detail on the safeguarding statutory notification log, including actions taken to safeguard the person.

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.

Staff and leaders did not have a clear understanding of how to make improvement which was consistent and included measuring outcomes and impact. We were told about a safeguarding referral and a member of staff told us they were not clear if there was a learning outcome made clearly to all staff. Leaders told us, “We promote a culture of learning” and, “We actively encourage continuous learning and improvement.” However, during this assessment we identified processes were ineffective to support learning, improvement and innovation to actively contribute towards safe and effective practice.

We identified processes which were ineffective to support learning, improvement and innovation to actively contribute towards safe and effective practice. The incident report including actions and lessons shared, did not always show the lessons learnt specific to the person and that incident and some sections of the report were incomplete. This limited opportunities to learn and improve the service provided to people. The complaints log did not include all complaints raised and we were made aware of another complaint raised which was not documented. The Service Improvement Action Plan Radar did not include actions from the service’s Provider Validation Review. When reviewing these documents, it was unclear how they linked together to inform effective oversight and action taken. This meant people were at risk as the service did not have systems or processes established and operated effectively to ensure compliance, assess, monitor and improve the quality and safety of the services provided.