Wray Park 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.

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.

This service scored 43 (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, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

Leaders had a hands-on approach that was compassionate, yet people would benefit from there being a more, respectful, person-centred care model. Leaders had not developed a clear vision, strategy or set of values, aims and aspirations for the service which staff knew about and followed. When asked about why sensor lights were being used in some people’s rooms when they were unable to mobilise, they told us, “Sometimes if [person] is in distress and she just moves her hand (the sensor alarm will go off).” They then said that it was a reminder as, “You may forget that someone is there, it’s part of it [the reason the alarms are used].” Leaders had not considered that people being cared for in bed would become socially isolated. Isolation causes rapid mental decline. It increases rates of depression, anxiety, and a feeling of abandonment. After the inspection the provider told us, “The activity coordinator will be more proactive to go to the rooms, but also the staff themselves. That will be part of what we will introduce.”

Staff we spoke with did not have knowledge of the values set by the provider. One member of staff told us they did not know the values, whilst another told us, “More growth and focus on how we achieve our goals.” When asked how they ensure staff understood the values, the registered manager told us, “By observing how they work, watching their interactions with the residents, speaking to them one-to-one, supervisions and things like that.” However, this was not effective in ensuring staff understood and worked to these values.

However, the provider listened openly to our feedback and showed a genuine desire to act on the concerns we raised. They told us, “It's about looking at it in a positive light to make sure that all the things that have happened don't happen again. Because there's nothing on here that we can't do.”

There were staff and relatives that fed back that the service was well managed. Comments included, “I feel like everyone is happy here. We live like a family. I don’t think it of as a care home. We do things as a team” and “[Registered manager] is the manager, it’s a hard job. He has helped me out with my mother; he has steered me in the right direction. It is a well-run place.”

The provider did not always 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. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

Leaders failed to have the skills, knowledge and experience to provide support and guidance to the staff team. The provider failed to maintain oversight of the quality of care being provided. Reviews of people’s care plans had not ensured a fully inclusive and collaborative process of care plan development. Leaders had not ensured staff had completed core, or specific training in accordance with people’s individual needs to promote equality, diversity, inclusion and engagement.

We identified 1 member of staff was working 6 days on most weeks and working in excess of 60 hours a week. This member of staff was also required to be on call when they were off duty on the basis that they lived in accommodation at the service. Working excessive hours a week increases the risk of severe physical and mental burnout. It also harms placed people at risk as exhausted staff are more likely to make errors.

However, it is important to note that despite these operational breaches, leaders themselves were warm, compassionate individuals who we observed had developed genuine and warm relationships with people and their families. Leaders had also assured us that they were eager to make the necessary improvements.

We found staff were not always confident around knowing when to speak up.

The registered manager told us they did not feel staff would always feel confident speaking up. They said, “It's difficult sometimes with some of the staff because they may think that they're going to get blamed or told off for it.” We did not see evidence of how leaders took action to address this to empower staff to speak up without fear of repercussion.

When we spoke with staff, they told us they would not hesitate to raise a concern. However, they also told us they felt there were no areas of improvement that were required at the service. This was despite us observing very poor cleanliness and maintenance of the environment.

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We found there was some inequality to staff who chose to live in the accommodation at the service, as they were also required to be available in emergencies during the night.

However, all staff were positive about working at the service and felt they were treated with respect. Staff said they felt they worked within an inclusive team which valued their differences.

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.

Governance systems were not operating effectively as they had not identified the significant shortfalls found within this assessment. They were unable to provide evidence of an effective system to assess monitor and improve the quality and safety of the services provided. Although a number of audits were taking place, these were not robust and often had very little detail on any areas for development or follow up. There was no evidence of how people’s best interests had been considered and how decisions were made to ensure least restrictive support. There were no audits of care notes, care plans, or direct observations of staff interactions with people (aside from a mealtime audit). This demonstrated there was no assurance on how the provider monitored the quality and safety of people’s care.

The provider was also the registered manager. There was no external scrutiny of the care provided to ensure the service was well managed. The quality of oversight by the provider therefore was not checked. However, the provider has confirmed that they have commissioned an external consultant to undertaken audits at the service and to provide additional training to staff.

Services that provide health and social care to people are required to inform the Care Quality Commission (CQC) of important events that happen in the service. Leaders had not informed the CQC of safeguarding concerns that had been raised by the local authority.
 

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.

A lack of oversight and monitoring impacted the effectiveness of collaborative working and the sharing of information. This was because quality improvement processes were not routinely taking place. People’s care plans were not always completed, up to date, detailed or accurate therefore we could not be assured that partnership working was always fully supporting effective care.

However, health care professionals were complimentary of the joint working with the service. One told us, “I can only praise this care home for their attention to detail and their active support of the well-being of all [people] in their care. They are consistently proactive and caring towards the needs and requirements of patients and colleagues.”

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

Where incidents had occurred, there remained a lack of analysis of these to look for themes and trends. Leaders had not considered that incidents where people had sustained skin tears and bruising may have occurred as a result of poor moving and handling practices by staff. There was no detailed analysis of people’s emotional distress to understand how to support them.

We saw from staff meeting minutes in April 2026, the staff raised concerns that due to having to do the washing up following serving lunch they did not have enough time to spend with people. The provider responded, ‘I’ve seen staff in the lounge doing nothing with residents. That is an observation. It’s about time management, not just the workload.’ Action was taken to get an ancillary member of staff to do the washing up at lunch. However, sufficient action had not been taken by leaders to drive improvement with interactions as we identified the same concern on the day of the inspection. The provider told us after the inspection, they were going to take more robust action to address this.