Wellington Park 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 requires improvement. At this assessment, the rating has remained 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 governance.

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.

People received care and support from a staff team that was supported by their leaders and guided by appropriate processes and policies. This created a positive culture within the service and a protected environment for people and staff.

Care staff and managers provided person-centred care by listening to people and their relatives and trying to accommodate their wishes. A relative told us, “The home is lovely and [person] is well cared for.”

Leaders supported staff by setting clear expectations and encouraging regular discussions around best practice. The service held regular staff meetings in which issues were discussed and learning shared. Staff spoke positively about the culture and atmosphere in the service. A staff member told us they were “very happy” at the service and that they enjoyed their job.

Leaders, including senior workers and nurses, had the skills, knowledge, experience and credibility to lead effectively. They worked as a team and addressed poor practice that could affect the quality of people’s care.

We observed leaders were visible and offered support to the staff team regularly. The nurses understood their roles and responsibilities and ensured the service ran smoothly in the absence of the registered manager. They communicated effectively amongst each other and maintained clear records of handover of information.

Relatives felt leaders were responsive, helpful and engaged well. Their comments included, “The management is very good; they will always speak with me” and “The manager is very approachable.”

The service fostered a culture where staff felt they could speak up and their voice would be heard. Leaders encouraged staff to escalate concerns promptly and listened to their suggestions.

Staff understood their responsibility to report concerns internally and externally to other organisations if needed. They felt comfortable to engage with the leaders and voice their opinions. A staff member told us, “If there is something I’m not happy with, I can go to [manager] to talk about it.”

Staff and leaders acted with honesty and transparency. They liaised with people’s relatives effectively. A relative told us, “We are always updated on any concerns that arise.”

The service 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 staff team consisted of individuals from diverse cultural backgrounds with varied experiences. The team was made up of a blend of long serving and newer staff members. This created stability within the service and ensured people received support from staff who were compatible with their personal preferences and needs.

Staff reported being included in the development of the service.

The service did not always have clear responsibilities, roles, systems of accountability or effective governance. The service did not always act on the best information about risk and outcomes.

The managers and senior staff undertook a series of audits to assess and improve the quality of service. However, the existing quality assurance system had not identified the issues we found in our assessment, including issues regarding environmental safety. Where audits had identified concerns, prompt action was not always taken to address them. There were also contradictions in the findings from certain internal audits, which meant issues were not always effectively identified or promptly addressed. For example, a health and safety audit had not identified the concerns we found around bed rails, radiator covers and damaged furniture. However, issues with bed rails were identified in another type of audit, although there was no evidence of any remedial action. Maintenance issues reported by staff were not always actioned, indicating a lack of management oversight.

There were shortfalls in risk management. The service had failed to acknowledge the importance of the findings from their building’s fire risk assessment. Managers were not proactive in allocating resources to ensure health and safety work was completed promptly to reduce potential risks.

The registered person was not fully aware of their duty to notify CQC of certain events, such as safeguarding concerns which they had reported to the local authority and outcomes of Deprivation of Liberty Safeguards (DoLS) authorisations applications. We raised the issue of statutory reporting with the provider, who stated they would review their practices to ensure all notifiable events are appropriately reported to CQC.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. Staff shared information and worked together with partners to improve the quality of care for people. We found clear evidence of good interactions between the service and other agencies.

The managers worked closely with people, relatives, health and social care professionals and the wider staff team to continuously learn and improve the service. The learning culture was based on dialogue and trust.

Staff had a clear understanding of their roles and responsibilities and cooperated with the managers in developing and improving the service.

The service gathered feedback from people and their relatives through various methods, including satisfaction surveys, to drive improvements. The managers analysed the findings and liaised directly with people and relatives to address any concerns. Relatives confirmed they have had surveys to fill in.

In response to some of the concerns we identified, the registered manager promptly submitted an action plan detailing the improvements they intended to make. We will check these in the next assessment.