Wellburn 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 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.

The service was in breach of legal regulation in relation to effective monitoring of safety and outcomes for people.

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 registered manager had a vision and culture for the home.

The registered manager and staff described how those they cared for were at the centre of everything they did. Staff commented how the home was ‘a family’ and how everyone worked together to ensure people felt at home and loved.

However, there were several issues highlighted during the assessment which were not in line with this view or did not demonstrate the vision and culture was embedded in practice.

Staff told us they did not always feel team leaders demonstrated a supportive approach which they found unhelpful at times. In the recent staff survey, they had stated stress and workload to be a challenge. These observations did not always align with the culture and values of the organisation.

The provider had developed new values, and the registered manager had spent time with staff to understand what was important to them and what it meant to work at Wellburn House. This demonstrated a desire to bring the team together and improve in this area. There were displays in the home highlighting these values.

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 the organisation. Leaders did not always demonstrate they had the skills, knowledge and awareness to lead effectively.

The shortfalls found at our first day visit did not evidence that leaders always ensured the service was safe, good quality care was being delivered and risks were well managed. Although we did not find these shortfalls had led to any harm to people, there was a risk of harm occurring.

These issues had not been identified or there had not been an adequate action taken to address them prior to our visit.

Managerial staff were more visible and responsive at our second day visit.

Many of the shortfalls highlighted on the first day visit had been addressed ahead of our second day visit which demonstrated the provider and registered manager were keen to make improvements to the service and learn lessons.

The registered manager was open and honest about the service and her personal development goals for the future. They had completed a management course with local authority colleagues and was currently working on a Skills for Care management module.

Staff spoke positively about managerial support and how they were, “always willing to lend a hand when needed.” A healthcare professional told us, “The home registered manager is very responsive and really wants to get it right."

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

Staff commented how they would have no hesitation in raising concerns about any aspect of the service or the care of people if they were unhappy about something. The registered manager held various staff meetings, the service had an ‘Employee Voice Champion’ and surveys were undertaken to provide platforms for staff to speak up.

Guidance on whistleblowing and speaking up was available and accessible to staff.

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.

Leaders invited staff to contribute to all aspects of the service to improve workforce relations. Staff completed training in key areas to reinforce good working practices.

Staff were able to work flexibly, and reasonable adjustments were made to support staff in the workplace.

Staff enjoyed inclusive social activities together and shared cultural and celebratory events with people in the home.

A system to ensure regulatory requirements were met was not always effective.

Whilst there were clear responsibilities and systems of accountability, the findings on our first day visit identified shortfalls across several areas. This did not provide assurances that existing governance arrangements, audit processes and managerial oversight was being proactively or effectively used to identify shortfalls, maintain compliance and drive improvements.

The home management team did not always know or act on the best information about risk, performance and outcomes which was apparent when discussing skin integrity and wound management for example.

The registered manager took prompt action to address issues highlighted at our first visit and these were remedied by the time of our second visit. This demonstrated a responsiveness to deal with matters highlighted in a proactive, timely and efficient manner.

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.

There were effective and well-established links with MDT colleagues and referral pathways to support continuity and a joined-up working.

Staff worked with healthcare colleagues and services to ensure care was coordinated. Staff shared information appropriately which minimised unnecessary repetition for people who move between services.

The registered manager was working with district nursing services to further improve communications and referral processes to help improve partnership working.

The home had good links with their local area which ensured people could maintain connections with their community.

The provider did not always focus on continuous learning and improvement across the organisation.

There were missed opportunities to identify areas for improvement, service development and learning due to ineffective governance processes.

While staff were keen to get involved in learning and improvement initiatives, these did not always contribute to safe care, best practice and improved outcomes for people. The provider was reactive to issues and did not always proactively identify areas for growth.

Whilst governance systems were not always effective to promote learning and improvements, there were some creative thoughts to improve quality and outcomes for people by way of meaningful activities. The service had taken part in a caffeine reduction trial to improve with the aim of improving outcomes for people, and the home had seen some positive results. The registered manager reported less distressed reactions and a reduction in the number of falls.

There were some innovation initiatives in place. This included a dedicated ‘Energy Champion’ to ensure the service was supportive of environmentally friendly and green initiatives.