Wisteria House Residential Home - Rutland

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.

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 did not have a clear shared vision or strategy. They understood the challenges and the needs of people and their communities.

Some improvements were needed in maintaining accurate records and ensuring learning from audits was fully embedded. Further time was required for these processes to become consistent and sustained across the service.

The provider had introduced an electronic care system (PCS) 12 months ago, but recording remained split between electronic and paper formats. Staff told us this was confusing and sometimes led to duplication because information was stored in different places. This meant the system was not being used effectively to support safe and consistent record‑keeping.

The registered manager was open about the challenges, saying they felt more confident with paper-based systems and planned to undertake further learning to strengthen their use of the electronic system. The registered manager said, ““I preferred when we were paper. We have gone electronic and it’s not my greatest strength; I will be looking to get some more learning around this.”

There had previously been concerns about a divide between staff teams. Staff meeting minutes referred to past issues with team dynamics, which the management team told us had since been resolved. They also noted an isolated conduct issue that had not recurred. The registered manager reported good staff morale, a positive culture, and that staff were now working well together.

The culture within the service was person‑centred. People and staff spoke positively about the provider, and staff told us they enjoyed working at the service.

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.

Safeguarding concerns had been identified and action taken to reduce the risks, including referrals to the funding authority. However, the provider did not notify CQC, despite this being a regulatory requirement. These notifications were only submitted retrospectively after the inspection. The registered manager accepted this was an oversight and confirmed they would ensure all safeguarding incidents are reported to CQC in future.

Staff told us the management team were compassionate and supportive, and that they led by example. They said the registered manager was visible within the service, regularly spending time on the floor and working shifts alongside staff.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff described how freedom to speak up was discussed and understood within the service. They told us information was available in the office policies, the staff handbook, and through guidance on whistleblowing. One member of staff said they would feel able to raise concerns by escalating to senior management or, if needed, by contacting CQC.

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 they were treated fairly. One staff member described how, when an extra shift needed covering, the registered manager checked whether they were happy to work it and, on other occasions, picked up shifts themselves. Staff said this approach helped them feel supported.

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.

Leaders did not always have effective oversight of care delivery, treatment and support. The registered manager told us they were not completing audits for medicines, accidents, incidents or falls, and although they said they reviewed care plan audits and medicines, there were no records to demonstrate this. As a result, they had not identified several shortfalls found during the inspection, including issues with medication, auditing, actions required following a fire inspection, staff training, and reportable incidents. This meant there was limited managerial oversight to identify concerns, monitor trends or drive improvements.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. For example, with CQC.

Professionals involved with the service told us the provider worked in partnership with them.

Strategic links had also been made with other local community groups, to benefit people living at the home, for example the provider had visits from the local school.

One professional said, “All staff at wisteria house are very helpful and easy to communicate with they are helpful and aware of all the needs of the patients. They are always in prompt communication with all health professionals. Discussions are always held with the senior member of staff and residents where appropriate before decisions are made.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider had policies in place, but neither staff nor management were consistently following them. For example, staff had not completed the required documentation following a person’s fall, despite this being clearly set out in the provider’s procedures. The medicines policy stated the registered manager should complete regular medication audits, but we found no evidence these had been carried out.

The registered manager acknowledged these shortfalls and assured us that, following feedback, a medication audit process would be implemented, policies would be reviewed and updated, and staff would be reminded of their responsibilities during team meetings to ensure policies are followed in practice. The registered manager welcomed our feedback and had started to take action to address the issues identified during our inspection.