Wilbury

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 remained Good. Governance systems were in place and continuing to embed following a period of management change. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Leaders promoted an open and person-centred culture. People spoke positively about the atmosphere of the home. One person told us, “It’s lovely here, I feel calm and comfortable.” Another person said, “I can’t complain, I do feel safe, I am very happy.” Staff reported that the culture of the service had become more transparent following the recent change in leadership. Leaders had established a culture of shared responsibility. One staff member explained that the implementation of the new electronic system will help the team work more effectively and said, “It will help us access information more easily and keeps everyone on the same page.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. The service was in a period of transition. At the time of our assessment, there was no registered manager in post, however a new manager had been appointed and was awaiting registration with CQC. Staff spoke positively about the changes in leadership and noted an increase in visibility. Staff told us they felt the manager was approachable and that there was a stronger leadership presence within the home. However, leadership systems were not yet operating consistently. Our review of governance records, including staff supervision, appraisal and complaint records, showed that while some supervisions and appraisals had taken place, they had not been completed in line with the provider’s own expectations. The manager explained that due to multiple changes in the management team over the previous year, historical records from 2025 could not be located, and only records the manager had personally completed since starting were available. The manager had identified these gaps and was in the process of implementing a central tracking system to ensure oversight. However, because these arrangements were not yet fully embedded for the whole team, there was a risk that gaps in staff skills or wellbeing would not be identified or addressed.

The provider fostered a positive culture where people feel they can speak up and their voice is heard. Leaders promoted an environment where staff felt safe to raise concerns. Staff felt comfortable identifying and reporting potential risks, which directly contributed to the ongoing safety and development of the service. Staff understood the whistleblowing policy and were confident that leaders would act on any issues raised. One staff member told us, “I would have no hesitation in reporting any concerns.” The manager operated an "open-door" policy, and staff reported being listened to when they made suggestions for improvement.

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. The provider promoted equality and diversity within the team. Records confirmed that staff had completed mandatory equality and diversity training. Staff reported that they felt respected and that the workplace was inclusive of diverse backgrounds. Leaders had created a supportive work environment, which assisted in building a dedicated team focused on providing fair care to people. One staff member stated, “We are a diverse team, and we all get along well; the manager respects our different backgrounds.” The leadership team ensured the workplace was equitable by considering the individual needs of the workforce, such as supporting specific cultural or personal requirements.

The provider did not always have clear responsibilities, roles, systems of accountability or effective governance. They did not always act on the best information about risk, performance and outcomes or maintain complete records to support assurance and service improvement. Governance and quality monitoring systems were not always effective in relation to how concerns were recorded, escalated and monitored. We identified gaps in these processes. For example, care records for one person stated they, “did not want to be in this broken home anymore.” Although staff had documented that this would be followed up with a senior member of staff, there was no record of any further action or investigation, and the concern had not been logged as a complaint or concern. Governance systems did not always provide an accurate or complete picture of the service’s performance. The manager said some historical complaint records for the previous 12 months could not be located. The provider could not fully demonstrate a complete audit trail or clearly identify themes to support learning and improvement during that period. While internal records showed no recent formal complaints, external professionals had raised concerns relating to missed care and safety. These issues related to historical governance arrangements during a period of management transition. At the time of our assessment, the provider had recognised these shortfalls and had begun to strengthen governance and oversight systems, including improvements to record-keeping, monitoring and assurance processes. This supported more effective oversight of quality and reduced the risk of people’s concerns not being recognised or addressed.

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 worked effectively with external partners to coordinate care. We found evidence of regular collaboration with health professionals, including the local GP and the community matron. Records showed the manager shared relevant information to ensure people’s health needs were met. One professional told us, “Referrals and engagement have always been appropriate.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. The provider demonstrated a commitment to continuous improvement through proactive monitoring and responsive action plans. The manager had identified historical issues with some management processes and were working through a structured action plan to rectify these. We saw learning being applied during daily handovers, where staff analysed people's changing health needs and adjusted care immediately. Staff used daily observations to drive improvements in the quality of care provided. For example, when one person was not eating well, staff coordinated with the chef and made a GP referral to ensure the person's nutritional needs were met. Staff were also encouraged to learn from one another by "matching" specific staff members to people where they had better success in motivating them to maintain their independence.