Wythall Residential Home

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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

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 requires improvement. At this assessment the rating has change to good. This meant the service was managed and well-led.

This service scored 64 (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 vision and values statement; however, they did not promote this effectively because staff had not consistently received value-based supervisions or appraisals. The registered manager was still developing the focus on learning and improvement, and recently introduced systems had not yet had time to embed. Despite this, staff told us, and we observed the service had a positive culture. The provider and registered manager also expressed their commitment to delivering good quality care.

The provider had capable, compassionate and inclusive leaders’ inclusive leaders at all levels. Leaders had appropriate skills, knowledge and experience. At our last inspection, the provider did not have a registered manager in post; however, they had since appointed an experienced manager who had registered with The Care Quality Commission. They were also the registered manager for 1 of the provider’s other services. Although we noted some improvements since our last inspection, the registered manager’s time was split between the 2 services, which created some limitations in leadership oversight. They understood their responsibilities under the duty of candour and told us they felt well supported by the provider, who visited the service regularly. One relative told us, “I do talk to the manager when I can find her, she sometimes works in the evenings”. The registered manager told us, “We work together as a team to bring out the potential in everyone”.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.The provider’s policy outlined how staff could raise concerns anonymously. However, the policy required updating because it did not include the name and contact details of the whistle blowing hotline. Strengthening this information would enable staff to access clear guidance and raise concerns through the appropriate channels. Other details such as the local authority and the Care Quality Commission details were included in the policy.
 

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 employed a diverse workforce and made reasonable adjustments to support staff with protected characteristics. The registered manager gave examples of how they adapted working arrangements to meet individual needs, which helped promote an inclusive and fair workplace culture.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. Governance and systems were not always effective or robust. The registered manager worked on a part time basis as they were also the registered manager at 1 of the providers other services. There was no deputy in place to provide management cover when they were not present. This limited the oversight of the service and the provider’s ability to ensure consistent management, monitoring and support. This reduced assurance that risks, concerns and areas for improvement were identified and addressed in a timely manner. During our visit the provider confirmed they would provide additional support for the registered manager. Regular checks and audits were carried out; however, they had not identified the issues we identified during our assessment and detailed in this report. We requested evidence of provider oversight and checks; however, none was provided. This meant the provider could not demonstrate effective monitoring of the service or assurance that risks and shortfalls were identified and addressed in a timely way. Although the registered manager told us the provider visited the service regularly, this was not supported by documentary evidence. Policies were shared with staff through the provider’s online system and overseen by senior leaders, but some were not aligned with current guidance or lacked essential information. A business continuity plan was in place to guide staff during emergencies such as loss of power, and the registered manager submitted statutory notifications as required.
 

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. Staff worked well with visiting professionals, who told us communication had improved and staff followed their advice promptly. Healthcare professionals reported positive relationships with the service and said staff contacted them appropriately when people’s needs changed.

The provider had started to strengthen their focus on learning and improvement. During our assessment the provider introduced a continuous improvement plan to enable them to monitor and track areas of improvement identified from this assessment and their own internal auditing processes; however, this was newly implemented and needed time to embed.