Well Springs Nursing Home

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 good. At this assessment the rating has changed to 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 61 (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's values and expectations were not always consistently reflected in practice.

We observed occasions where care was task-focused rather than person-centred, and people were not always offered choices, involved in decisions affecting them, or supported in ways that promoted dignity and independence. Feedback from people and relatives, alongside our observations, indicated there were limited opportunities for meaningful engagement and social interaction.
Staff understood the provider's values and expectations. The provider regularly reinforced messages about quality, care delivery and professional conduct through meetings, supervision and management processes. Despite this, these values and expectations were not consistently embedded across the service.
 

Not all leaders understood the context in which the provider delivered care, treatment and support, and leadership oversight was not always effective in ensuring safe, high-quality care.

During the assessment we identified concerns relating to medicines management, risk management, admissions processes and end-of-life planning, which indicated systems were not always subject to sufficient monitoring or review. The provider could not always demonstrate effective arrangements for overseeing and developing clinical practice, reducing assurance that safe and consistent care was being delivered.
However, people, relatives and staff spoke positively about the leadership team, with 1 relative telling us, "The manager is approachable and has been very helpful and understanding," and staff describing managers as supportive and fair.
 

The provider had systems in place to encourage people and staff to speak up.

Staff told us they felt confident speaking up about concerns and described managers as approachable and responsive. Records showed concerns and complaints were documented, investigated and responded to appropriately. A relative told us, "If I have any concerns, I talk to the manager who soon sorts them out."

Staff had opportunities to contribute their views through meetings, supervision, surveys and day-to-day discussions with managers. We saw examples where staff feedback had informed changes to aspects of the service, including the working environment and operational processes.

Whilst some staff feedback indicated the outcomes of concerns raised were not always fully communicated, this was often linked to the need to maintain confidentiality. Overall, staff and people using the service were able to raise concerns and contribute to the development of the service.

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 respected, valued and treated fairly at work. Staff said they felt able to raise concerns without fear of unfair treatment. We did not receive feedback suggesting staff had experienced discrimination or inequitable treatment in the workplace.
Recruitment processes were designed to promote equal opportunities and help ensure suitable staff were appointed to roles. The provider employed a diverse workforce which reflected the backgrounds and needs of people using the service.
 

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Although a range of audits and monitoring activities were in place, these had not identified the concerns we found during the assessment. These concerns included issues relating to care planning, risk management, medicines management, emergency evacuation planning, end-of-life care planning and the oversight of unexplained injuries. Care record audits had not identified gaps in risk assessments, inconsistencies within care records or occasions where identified interventions had not been implemented.
However, managers completed regular audits, service checks and monitoring activities, demonstrating a commitment to reviewing the quality and safety 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 service was actively involved in wider community and sector initiatives. This included links with local schools, recruitment and development partnerships with educational providers, and participation in research and improvement projects designed to enhance care provision. People were supported to maintain important relationships and connections within their communities, including access to religious support, hobbies, interests and family relationships. The service also participated in wider improvement initiatives and community partnerships to support staff development and service improvement.
The provider demonstrated a strong commitment to maintaining community links and creating opportunities for people to remain connected with activities, groups and relationships that were important to them.
 

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. Systems for learning and improvement were not always effective in driving sustained changes in practice.

Although incidents, safeguarding concerns, falls and complaints were reviewed to identify themes and trends. However we found recurring issues relating to people leaving or attempting to leave the service, falls, unexplained injuries, risk management and clinical oversight. This meant the provider could not always demonstrate that learning from incidents, audits and quality assurance activities had been effectively embedded to reduce the risk of reoccurrence.
However, the service demonstrated a commitment to improvement through participation in external initiatives, research projects and development programmes, and by allocating staff champion roles to promote good practice and continuous development.