Woodside Lodge

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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 assessed a total of 2 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was good. Our rating for this key question has deteriorated too requires improvement. We found the provider was failing to meet their legal requirements and were in breach of regulation. The provider failed to ensure they operated good governance and leadership roles were ineffective to consistently monitor, identify and drive improvement. We found a number of significant concerns at this assessment and were not assured that the providers governance ensured people always received safe, effective, good quality care. Staff told us they felt able to speak up and leaders of the service were approachable.

This service scored 62 (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.

The provider had policies and procedures in place to support staff to speak up and raise concerns. Staff were encouraged to be aware of and review policies and procedures in place around workplace culture, bullying and discrimination and the registered manage proactively encouraged this.

The registered manager told us that they were passionate in ensuring that they supported staff wellbeing and strived to create an open and honest culture within the home. All staff we spoke with told us they felt confident to speak up and felt supported by the leadership team.

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.

When discussing some of the short falls we identified at this assessment the registered manager and leaders could not always demonstrate they had a sound and sufficient understanding of all required responsibilities and legal requirements. Staff told us they felt the home was well-run and they had built good relationships with leaders.

Processes for identifying, capturing and managing organisational risks and issues were ineffective and did not drive improvement. They were not robust and did not systematically identify the widespread and significant concerns identified at this assessment. This included concerns we found in relation to medicines management, environmental risks, accurate and contemporaneous care records, the need for consent and compliance with safeguarding and DoLS statutory requirements. The registered manager did not demonstrate that they maintained oversight of delegated tasks, for example delegated tasks in relation to the health and safety of the building. Where records evidenced non-compliance, the provider failed to take actions to address and reduce the risks to people. This included water temperature checks and implementing identified actions from the fire risk assessment which remained outstanding. We found multiple examples where the provider had failed to ensure people's care records were contemporaneous, accurate and consistently up to date to reflect their current needs and care provided. The provider completed monthly audits of accidents and incidents. These were not effective and did not identify multiple examples where the provider had failed to notify relevant bodies where this was required. Systems to ensure staff were sufficiently trained and competent in their role were not effective. The provider failed to have appropriate oversight of the recruitment process which resulted in staff being employed into the service without having all the required documentation in line with statutory requirements. Governance systems around the need for consent were ineffective. Records lacked consistent information regarding people's capacity to consent or where their memory or cognition was affected by a condition, such as a diagnosis of dementia. There were no mental capacity assessments and best interest decisions for most people where this was required.

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.