Wyndham Manor 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 inspection 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 the legal regulation in relation to good governance.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Improvements were required to ensure people achieved positive outcomes and staff were enabled to contribute to the development of the service.

Some staff told us that the culture at the service was not always positive. The provider was aware of the issues and were supporting staff through the changes they were making. Training, meetings, supervision sessions and appraisals were being organised and undertaken.

Our findings at this assessment did not evidence that leaders had the capacity and capability to ensure the quality and safety of the service was high, quality care was delivered and risks were well managed.

The registered manager was on leave at the time of our inspection. The deputy manager was providing management cover with support from the senior management team. The provider was strengthening management systems at the home and was recruiting an additional deputy manager.

The provider was aware of the issues and were supporting staff through the changes they were making. Training, meetings, supervision sessions and appraisals were being organised and undertaken.

We found the senior management team were open and honest during the assessment and displayed a commitment to ensure improvements were made and sustained.

Improvements were being made to ensure staff felt enabled to speak up. Prior to our assessment, meetings and staff supervision sessions and training had not been carried out as planned.

The provider was already aware of the issues and were working with staff to support them. Further training, meetings and supervision sessions and appraisals were being organised and undertaken.

An effective system was not fully in place at the time of our inspection to ensure there was workforce equality, diversity and inclusion. Some staff said they did not always feel valued or included.

The provider was already aware of the issues and were working with staff to support them. Further training, meetings and supervision sessions and appraisals were being organised and undertaken.

An effective quality monitoring system was not in place to ensure regulatory requirements were met. There were shortfalls across the service in relation to medicines management, safeguarding, staff support and training, nutrition, continence care, MCA, the assessment of risk and care planning.

The provider was not meeting legal requirements in relation to informing CQC of all notifiable events at the home. They had not informed CQC of the outcome of all DoLS applications.

The provider had already identified many of the issues we found. They had introduced new recording and monitoring systems as well as a new electronic care management system. It was not possible to check how effective these new systems were because they had just been introduced and were not yet embedded into practice.

They had also formulated an action plan to ensure that improvements were made in a timely manner and make sure the new improved systems were embedded into practice.

The local authority was monitoring the quality of the home and supporting them to ensure the correct procedures were in place to keep people safe.

A representative from the local authority told us that the provider was working with them to make the necessary improvements.

An effective system was not fully in place to identify and share lessons learned from accidents and incidents, safeguarding concerns and complaints so action could be taken to minimise the risk of any reoccurrence.

The provider had already identified many of the issues we found. They had introduced new recording and monitoring systems as well as a new electronic care management system. They had also formulated an action plan to ensure that improvements were made in a timely manner and make sure the new improved systems were embedded into practice.