Wall Hill Care Home Limited

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 changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service continued to be in breach of a legal regulation in relation to governance at the service.
 

This service scored 32 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights. They did not understand the challenges and the needs of people and their communities.
Staff told us the service was not suitable to accommodate and support people with learning disabilities.
The provider agreed to support people with learning disabilities and 1 person with substance misuse, who then moved into their service. However, the provider had not indicated to us as the regulator they had the correct skills or experience to support people with these needs. The provider also did not put training in place for their staff, prior to us raising this.
We reviewed the provider’s statement of purpose. This did not reflect the principles of Right Support, Right Care and Right Culture [This is a national policy which providers must conform to when supporting people with learning disabilities and/or autistic people]. The provider had notified us to add this support type to their records; however, they had not told us how they intended to meet the principles of Right Support, Right Care and Right Culture, therefore it was not accepted at the time of this inspection.
The culture of the organisation did not promote choices, independence and good access to local communities. The culture of the organisation did not promote safe care and treatment, during this inspection we raised 11 safeguarding concerns for people who lived in the home. Where people experienced distressed emotions, they were not always supported by staff and we were required on 2 occasions to ask staff to intervene to keep people safe. There were limited activities for people to complete throughout the day, this meant the culture of the organisation did not support people to live meaningful lives.
 

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation.
At the start and during this inspection there was a registered manager in position and a new manager who started November 2024. The registered manager put in an application to de-register from their position during this inspection and the new manager shared their plans to register as registered manager.
We raised concerns over the lack of action taken in response to the previous inspection where we served 2 warning notices. The provider had to be compliant with the warning notices by November 2024. At the start of this inspection, 20 March 2025, we checked the provider was now complaint with the warning notices. However, the provider had failed to meet these warning notices. The care they were responsible for continued to fall below what was legally required. The new manager discussed how they were planning to improve the service, however these improvements would need to be embedded to ensure they were sustainable for the future.
Staff told us they felt confident in the new manager’s ability to lead the service, with 1 staff member commenting, “It’s been better [since the last inspection], we’ve had [the new manager] in. The [new manager] has put us in the right place with what we should be doing. You can speak to [the new manager], they know the answer.”
 

Staff did not always feel they could speak up and their voice would be heard. One staff member told us they felt able to speak up. They said, “I would now go to [the new manager]. They are very approachable.” However, another staff member told us they felt “silly” speaking up, because nothing was done when they last spoke up about a concern. We raised a safeguarding referral about this and asked the [new] manager to investigate.

There was a whistle blowing policy in place which was accessible to staff.
 

Whilst the provider recruited staff from a variety of backgrounds. Staff were not always included in the service.

Staff told us they had the opportunity to take part in team meetings. However, some staff told us they did not have the opportunity to make suggestions or provide their opinions of the care provided. We reviewed minutes of a senior staff meeting where staff expressed, “They were tired and working well over their hours and felt they could not say no.” We could not see the provider had taken action to explore this further or make changes to support their staff team. Although, the minutes also recorded the staff were positive about the [new] manager being in post.
 

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on information about risk, performance and outcomes, or share this securely with others when appropriate.
The provider’s systems were not effective when escalating concerns when monitoring people’s fluids. Whilst a fluid tracker recorded how much fluid a person had consumed, there was no oversight or escalation when people did not consistently meet their target fluid intake. In response to our feedback, the provider contacted a health professional to seek clarity when fluid concerns needed to be escalated for people. However, failure to embed a system to effectively monitor and escalate concerns placed people at risk of harm.
When changes occurred within people’s health and wellbeing, the provider’s systems were not effective and care plans were not updated with people’s changing needs. This increased the risk of confusion within the staff team and therefore put service users at risk of harm.
The system in place for monitoring and analysing incidents and accidents was not effective. When incidents involving distressed behaviours were recorded, these were often recorded in brief without any follow up, actions taken, lessons learnt, or any reference to the duty of candour. Some incidents involving distressed behaviour were not challenged by staff or recorded as incidents. Failing to mitigate against future incidents and learn lessons placed people at risk of harm. The provider shared an incident and accident analysis for June -December 2024, they explained the current one was still under review. However, this was not shared with us. The June - December 2024 audit recorded there were no altercations between people during this period, however we reviewed records highlighting altercations between people on 3 different dates during this period. Therefore, this analysis was not a true reflection of incidents.
The new manager and consultant [who was supporting the provider at the time of this inspection] showed us a new system which was not in place yet. This new system was planned to ensure all accidents, incidents and near misses were recorded, analysed and followed up. However, this will require time to fully embed and become established in the service.
Whilst we reviewed some audits in place, these were not effective when identifying the discrepancies found during this inspection. For example, the previous month’s medicine audits had not identified the medicine discrepancies, furthermore the audit indicated the medicines fridge was recording maximum and minimum temperatures, and the audit confirmed people received their time specific medicines at the right time, when they did not. The health and safety audits had not identified water temperatures were not being taken.
The systems in place failed when ensuring people were not restricted without legal authorisation or best interest decisions. The provider identified family members to act on behalf of people without authorisation, despite this being a requirement within the warning notice.
The provider was making use of Artificial Intelligence [AI] to write some documentation, including care plans. Whilst the use of technology can greatly assist many areas of care, thought needs to be given to people’s right to confidentiality. However, the provider had not taken data protection into consideration. In response to our feedback the provider put this in place.
We raised concerns over the depth of the investigations carried out in response to the safeguarding concerns raised during this inspection. However, the provider raised a further safeguarding concern near the end of this inspection and the [new] manager carried out an investigation. This was much more detailed and robust.
Since the last inspection, the provider had made some improvements to the care provided. Some care plans had been updated and these were person-centred. Improvements were made to monitoring people’s bowels, where appropriate.
 

The provider did not always understand 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.
Visiting professionals told us the provider did not always share information or follow their actions or recommendations in a timely manner. Where concerns arose such as in response to changes in people’s presentations, behaviours or food consistency requirements, these were not always shared with the relevant professional in a timely manner.
The provider demonstrated they had ineffective internal communication systems to ensure information was shared as necessary with external professionals and organisations. In 1 example, incorrect information was shared with external organisations in relation to a person leaving Wall Hill Care Home. This lack of clear communication could cause anxiety for people or relatives involved or impede safeguarding investigations.
Despite this, staff told us the provider worked in partnership with other professionals. One staff member shared an example with us where they felt they had learnt a great deal from a visiting professional.
 

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system.
The provider had not taken appropriate action to address the breaches of regulation, which resulted in 2 warning notices being issued during the previous inspection. Similar concerns relating to safe management of medicines, best interest decision making and updating care plans in accordance with people’s changing needs, were found again during this inspection. This meant the provider failed to ensure the service they provided met the required level of care and they failed to act on information of concern in a timely manner. This placed people at risk of harm.
Staff told us the new manager was approachable and enthusiastic about improving the service. One staff member told us, “It’s improved and it’s getting better. It feels more relaxed. Staff were on edge before. Staff morale with was low before, but now it’s picked up, because [new manager] has come in and changed things around. Things change all the time, and we [staff team] need to be up to date with all the changes and training.”