The Well House

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 at the service.

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 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.

Although the management arrangements have been unstable, most of the staff have worked within the service for a number of years and fostered a shared vision. The deputy manager had worked hard to maintain the quality of the care and support provided to people and the staff. Staff supervision had been re-instated, and the culture of the service was embedded within the practice of staff. A relative reflected and told us, “It seems a happy place and I think the deputy manager seems to be good at leading her team fairly and firmly and appears to have a good rapport with them.”

The registered manager told us how vital it was for parents and relatives to trust staff and the service, and the support provided and promoting this was central to the culture of the service. A relative told us. “We trust them, and X always wants to come and stay.”

The provider had not always led the service effectively.

The management arrangements had not been stable or robust. The registered manager had not been managing the service for a number of months, and the deputy manager had taken on this role. However, the support provided to enable this was not appropriate, the deputy role was not replaced although some additional administration time was provided. The management role was extensive and included the regular assessment and re-admission of people receiving respite care. There was a constant turnover of people at the service. The provider could not be assured that all management duties had been completed. For example, the provider was not aware of the issues identified during this assessment process. This included the risks identified around the reduction of environmental risks.

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

Staff told us they were able to share their views on a regular basis. Staff had open access to the deputy manager and had the ability to contact the registered manager if they wanted to. We observed a relaxed and pleasant relationship between staff. They greeted each other and exchanged pleasantries and a joke, as they did with people living at the service.

Staff meetings were used to communicate and to listen to staff. For example, staff suggested the use of walkie talkies to improve communication in the annex buildings. These were provided and were in use.

Staff told us they were aware of the whistle blowing procedure and aware of external contacts that could be used if required including the local authority and 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.

The managers were committed to promoting equality and inclusion across the workforce. The team was multi-cultural, and the deputy manager told us how they ensured everyone felt included. For example, providing time for prayer if needed.

Staff told us their personal circumstances were respected. They told us family commitments were worked around to ensure staff had a good work life balance.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

Quality review and governance systems have not been fully established. There was no quality auditing review system to monitor any of the care documentation or risk assessments, the legal regulations or the quality statements. Auditing systems used did not identify shortfalls identified at this inspection. For example, the infection control audit did not identify shortfalls in the standard of cleanliness in the service.

Providers for existing services for people with learning disabilities and autistic people are expected to demonstrate how they are working towards meeting the requirements of ‘Right Support, Right Care, Right Culture’ (RSRCRC). There was no reflection on how these were being met within the restrictions of the environment and facilities.

The services policies and procedures have not been fully implemented and embedded into practice. For example, health and safety procedures had not been followed including procedures to ensure safe water supply. The complaints procedure was not being followed and needed to be updated to ensure all complaints were dealt with effectively. For example, for those complaints that may reflect on the registered manager.

This meant that the provider could not be assured that quality and safety of people was being maintained.

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 and managers were positive about the links they had established with local health and social care teams. They had regular contacts with them and could work proactively to gain the support and advice they needed to the benefit of people. They were currently working with a mental health team sharing daily updates when needed and having regular visits to ensure appropriate care and support and rapid response to any deterioration.

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.

We found there was a lack of robust quality monitoring processes to identify emerging concerns. There was no clear focus on improvement, for example the two breaches of regulation identified at the last inspection had not been fully addressed.

The improvement plan used was not comprehensive and did not address all areas of concern identified at the last inspection for on-going improvement and did not pick up on all emerging concerns. This meant the provider had not demonstrated continuous learning and improvement for the service.

Records demonstrating how complaints and concerns were resolved did not demonstrate lessons were being learnt. This was raised with the managers to ensure suitable records were maintained in line with the complaint’s procedure.

There was evidence that staff were supported to continue their professional development and learning. A staff member told us, “I am doing my NVQ they are supporting me to do this, and the online training is also helping me in developing skills.”