Wolfe House Care 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 the governance of 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’s vision, strategy and culture was not fully embedded as people’s experience of the care they received was not always considered.

The values the service aimed to demonstrate in their working practice were displayed at the entrance of the home. However, no assessment regarding how these values were being met had been completed. For example, the impact on people’s experience due to concerns such as how staff engaged with people, the quality of activities available, the disruption to the environment and issues with cleanliness had not been considered. This demonstrated the positive culture which the provider, registered manager and staff team wished to create had not been fully embedded into the day to day running of the home.

In other areas we found the values and vision the team had for the service were embedded into practice and had a positive impact on people’s safe and effective care. Individual responses to people were caring, systems were in place to keep people safe and the service worked alongside a range of professionals to ensure people received co-ordinated and consistent support.

The provider had inclusive leaders at all levels who led with openness, integrity and honesty. However, continued development of the skills required to ensure good governance and monitoring systems was needed. We found there was an acceptance of a number of areas of concern, rather than looking to overcome issues such as ensuring people had the opportunity to go out, that the aesthetics and cleanliness of people’s home was maintained during the building works and how a more person-centred approach could be used when looking at how people spent their time. During feedback the registered manager and provider were clear they wished to address these areas and ensure people were placed at the centre of their support going forward.

The registered manager demonstrated a commitment to the service. Relatives told us they had trust in the registered manager and found they were approachable. One relative told us, “[Registered manager] is very passionate about the home and knows all of the residents well.” We found the registered manager demonstrated a caring approach in all their interactions and spoke of people, relatives and staff in a thoughtful and respectful way. Since taking the role of registered manager, they had worked hard to create a stable staff team who told us they felt valued and happy in their roles.

Staff told us they felt the registered manager created a positive environment where they were able to ask questions and develop their knowledge. One staff member told us, “I’ve learnt so much from [registered manager]. She’s like a knowledge sponge and we all know we can go and ask anything at anytime.”

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

Regular meetings were held with people to gather feedback on the service they received. Meetings involved discussions relating to if people felt safe, staff approach, activities, menu’s, any concerns and environmental matters. This gave people who were able to give verbal feedback to share their opinions and suggestions.

Staff members told us they felt able to speak up and would always receive guidance on any issues they raised. One staff member told us, “[Registered manager] is always available, even when she’s not here we can contact her for advice.”

The registered manager told us they had an open-door policy and made sure they were always visible in the service. We observed positive relationships between staff and the registered manager with discussions regarding people’s care taking place throughout the day.

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 told us they felt like a team and were all treated equally and fairly. One staff member gave the example of the registered manager supporting them to work more flexibly following changes in their personal circumstances. They told us of the positive impact this had made to their well-being and that of their family.

The registered manager told us they recognised the diversity of the workforce and wanted to reflect this in the support provided to staff. Examples included ensuring wherever possible staff had leave for religious and cultural events, encouraging staff to share food from their cultures, enabling staff to take longer holidays when travelling long distances to see family and considering all requests for flexible working.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about performance and outcomes. Information regarding risk was monitored and shares securely with others when appropriate.

Quality assurance processes were not always robust in identifying concerns within the service. For example, audits in relation in infection prevention and control were completed regularly. Although these referred to the cleanliness of the home, the responses were to check the cleaning schedules had been completed. There was no reference to visual checks identifying concerns found during the inspection. The registered manager told us they were responsible for planning the activities within the home although no guide as to how this should be personalised to people’s needs was available and no audits of people’s experience in this area were completed.

In other areas we found audits and quality assurance processes were detailed and effective in monitoring the quality and safety of care and support people received. For example, audits of medicines, accident and incidents and staff training demonstrated improved practices had been embedded and sustained.

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.

Professionals working with the service told us they felt people were well supported and there was good communication systems in place. Comments included, “I have been very impressed with the quality of care and support the staff provide the residents with” and “[Registered manager] and the rest of the staff always keep me informed and we have good clear and open communication.”

The registered manager told us they were aware of the importance of building links with the healthcare professionals and felt the positive relationships they had established helped promote trust and good communication. The provider had established some links with the local church although was in the process of trying to expand this to offer greater flexibility with visits.

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, and quality of life for people.

The service improvement plan for the home mainly centred around the development of policy and review. The plan did not include areas regarding the quality of the service people received where these had been identified through observation and review. Team meeting minutes showed the registered manager had noted a lack of engagement when staff were in the lounge with people. This had been discussed with staff although no review had taken place to monitor improvements. In addition, an external review of the home had found care plans in relation to end of life care required further personalisation. These shortfalls had not been listed on the service improvement plan, and no information was available to show how these would be reviewed or when improvement would be achieved. Both of these issues were identified as being of continued concern during our assessment. Following our feedback the registered manager forwarded an action plan of the steps they planned to take to address the areas identified.

In other areas the registered manager and provider demonstrated commitment to continued improvement. This included on-going plans to develop the environment, attendance at registered managers forums to ensure awareness of current best practice and working with an external provider to develop staff training opportunities.