Wymeswold Manor

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.

This is the first assessment for this newly registered service. This key question has been rated 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 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Managers were clear on the standards they expected, and team meeting minutes showed they set out where standards needed to improve and how they expected staff to act which included challenging poor practice where they saw it.

Staff were clear on what was expected of them and told us they would raise any concerns with the management team if required. However, leaders had not established and maintained a positive culture that consistently promoted high-quality, person-centred care. We found evidence that poor standards of practice had become accepted and were not challenged effectively. This created a culture where expectations of quality and accountability were unclear and did not reflect the provider's stated values or the principles of safe, compassionate care. Leaders had not taken sufficient action to identify, address, and learn from concerns, resulting in missed opportunities to drive improvement and ensure staff consistently delivered care in line with best practice and organisational values. A staff member told us, “I do believe we are not up to standard yet but given the right manager for the home we could be a truly fantastic team and have a very caring home for our residents.”

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, or they did not always do so with integrity, openness and honesty.

Leadership arrangements at the service had lacked consistency. Since the service registered in December 2023, there had been several changes in management, which had impacted the stability of leadership and oversight within the home. As a result, leaders did not always demonstrate a clear understanding of the challenges faced by the service or provide consistent direction to support continuous improvement.

Some staff told us they had seen improvements in management support in recent months; however, concerns remained regarding the consistency and effectiveness of leadership. One staff member said, “I do feel we need to be more organised and well managed, which over the last few months we have had more support from [managers]. However, I think what lets us down is not having a manager in place that truly puts the home and its team first. With the right management on a daily basis, I’m sure we would be able to keep on top of paperwork more.”

Feedback from external professionals reflected similar concerns. While they spoke positively about the day-to-day leadership provided by deputy managers, team leaders and care staff, they highlighted the impact of frequent changes in registered managers. One visiting professional told us, “Day to day management (deputy, team leaders etc.) is excellent. They are proactive and appear supportive to the team from my observations. However, there is a quick turnaround of home managers meaning care can suffer due to change in views etc. On the floor the home feels safe but any communications above deputy manager feel very fragile and uneasy at times.”

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

Most people felt able to speak up and raise concerns. Staff were confident raising issues with management and felt they would be acted upon. A whistleblowing policy was in place. Team meeting minutes showed evidence of staff being given opportunity to speak up and suggest improvements. However, there was limited evidence that concerns raised, or suggestions made through staff meetings were consistently reviewed, acted upon, or used to drive measurable improvements. This meant leaders could not demonstrate that staff feedback resulted in effective learning, change, or service development.

A staff member commented, “I feel very supported at work, if I have ever had a problem that I have raised it has always been dealt with as soon as possible.”

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 raised no concerns in this area and a staff member said, “I work set shifts to due to [personal], however, there has been times where I have needed to swap my shifts and management and colleagues have always made this possible. “

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, or share this securely with others when appropriate.

The provider’s failure to operate effective oversight systems significantly limited their ability to identify risks, monitor the quality and safety of the service, and address shortfalls in a timely way. This had created widespread and systemic issues, which the provider had not acted upon. For example, the most recent environment check, infection prevention and control audit, and medicines audits had all recorded no concerns and no actions identified. This did not reflect our inspection findings, and left people at risk of unsafe care. Gaps and inaccuracies in care plans had not been identified, prioritised or addressed through audits or other oversight mechanisms. There was also a lack of analysis of incidents, accidents, hindering effective oversight of themes and trends.

Overall, we found there was a lack of effective governance and oversight by the management team and provider. Systems were not robust enough to assess risks, monitor the quality of the service, or drive sustained improvement to positively impact people’s lives and outcomes.

The provider did not always have effective systems in place to ensure partnership working consistently supported positive outcomes for people. Oversight of people's care records was limited, and records were not effectively audited or reviewed to identify changes in people's needs. As a result, the provider could not be fully assured that referrals to healthcare professionals would always be made promptly when people required additional support or intervention.

People also continued to have fewer opportunities to access and participate in their local community than staff and leaders intended. This limited people's ability to maintain community connections and engage in activities outside the service. One staff member said, “We would love to even take them [people] for a walk, but more often than not we can't.”

However, staff demonstrated positive working relationships with external healthcare professionals and mostly made referrals when concerns were identified. Records showed staff communicated effectively with healthcare services to support people's health needs. Feedback from professionals was positive. One visiting professional told us, “I feel referrals are appropriate and the urgency of these are well considered.”

While staff worked collaboratively with healthcare professionals, improvements were needed to strengthen oversight arrangements and ensure partnership working consistently supported timely access to services and greater opportunities for people to engage with their local communities.

The provider did not 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 stated they were committed to improvement and had aligned some resources to complete this work during the inspection but was still reactively responding to issues and concerns to ensure regulatory compliance, rather than having a proactive plan to achieve innovative practice. Although the provider informed us of early signs of improvement following the inspection, they still had significant work to do to ensure the safety and quality of the service was improved, lessons learned and changes remained effective going forwards.