Wisteria Lodge

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 outstanding. This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

This service scored 89 (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 had a very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

Leaders had embedded this vision into an outstanding culture of openness, positivity and accountability, with a strong focus on ensuring people felt at home, valued and safe. The clinical manager told us, “We want people to feel at home here. It is their home and we are passionate about making it the best place for them.” People and relatives consistently described the service as “very homely”, “warm and happy” and “very harmonious”. One relative told us, “One of the selling points was the family atmosphere and that all the staff get to know the individual residents. This has proved to be accurate and applies to [all staff roles]. It also means that there is always a lovely atmosphere.”

Leaders placed a strong emphasis on promoting people's rights, equality and inclusion in the way care was delivered. They recognised and responded to people's individual needs, beliefs and preferences, ensuring people had a meaningful voice and choice in their lives. Their cultural and personal beliefs were respected, with staff advocating for their wishes and making reasonable adjustments to enable their inclusion. Leaders reinforced these expectations through ‘Wisteria Way’ staff standards training days, embedding compassionate, respectful and person-centred practice across all staff roles. The impact of this was evident in staff's understanding of their responsibilities. One staff member said, “I think our team are amazing. Everyone is caring, kind, respectful and works really hard to make sure [people] have got what they need.”

People’s and relatives’ experiences were supported by positive feedback from external professionals. One told us, “Wisteria Lodge provides a warm, relaxed and welcoming environment, with a clear focus on delivering person-centred care.” The consistency of feedback demonstrated that the provider’s values were deeply embedded in the culture and experienced by people, relatives, staff and professionals.

The provider had exceptionally inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

The management team were highly experienced and had worked at the service for many years. They were extremely capable in their job roles and had a complete and thorough oversight of the service. This had enabled them to monitor people’s care to the level where they were having consistently positive outcomes as detailed throughout this report.Throughout the inspection it was very clear how passionate they were about the people they supported and were driven by ensuring people lived the best lives possible. This was supported by people and relative’s feedback. For example, 1 relative told us, “We are extremely grateful for the wonderful care provided by staff and management. The care and nursing commitment from every single member of staff is impressive, they go about their routine with complete professionalism and compassion and always make you feel welcome when visiting. The family is also happy mum is now settled, well cared for and living her best life.” Another said, “There is good leadership, they [leaders] were amazing from the day I met them. I thought this is the place I want [person] to be; they ooze warmth and kindness.”

The provider also demonstrated a strong commitment to the development of staff, through training and career progression, they were proud of the team and spoke highly of them. Successes, achievements, and areas for development were shared openly with staff. This transparent approach encouraged involvement, strengthened relationships, and supported a culture of pride and continuous improvement. The registered manager described taking a number of the team to London to celebrate winning an award saying, “It was their award.” All staff told us they valued the management team’s approach. Comments included, “They [leaders] are really dedicated for the home, I’ve never seen people like them” and “They are so supportive of me, I feel lucky to work here.”

Throughout our inspection, we saw leaders to be highly visible and approachable and consistently demonstrated the service’s values through their daily interactions with people, relatives, and staff. Records also confirmed the management team always had direct oversight of the service by out-of-hours visits, working directly with people and using the electronic care system.

The leadership team’s expertise, experience and visible approach had a clear and positive impact on people and staff. Their strong understanding of the service and the people they supported enabled them to provide effective oversight, respond to changing needs and maintain high standards of care. Their passion, openness and commitment to the service’s values were consistently reflected in people’s experiences and in the confidence and pride expressed by staff.

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

Staff knew how to speak up and raise concerns when needed. Staff told us they had no concerns about practice and felt confident that action would be taken if issues were raised.

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.

The provider had developed a strong sense of belonging within the workforce. The diversity in the team had been promoted through awareness events and celebrating occasions. One staff member told us, “We are from different cultures, we have had a multi-national day, and we will soon be having a barbeque, we can bring in dishes from our culture.” All staff told us they were treated fairly and described good teamwork and mutual respect.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There was excellent oversight of the service from the provider’s management team, including the registered manager, clinical manager and quality manager. The service also had heads of departments such as housekeeping who had enhanced knowledge of their respective areas. As well as ensuring the home was delivering robust care at a service level, each member of the management team met with people using the ‘resident of the day’ approach. This provided additional assurance that people’s individual needs were being met and their experiences remained central to the running of the service.

Comprehensive auditing and monitoring systems were fully embedded in practice and used effectively to drive improvement. A wide range of audits were undertaken by designated staff, with clear oversight from the registered manager. These included regular reviews of care records, medicines management and infection prevention and control.

Governance processes included regular oversight of incidents, complaints and safeguarding concerns. Learning from events was analysed through meetings and reviews, ensuring lessons were identified and used to improve practice. Clinical governance was particularly strong, with numerous meetings involving a variety of staff to ensure information was shared effectively and everyone remained knowledgeable and up to date.

Leaders also proactively sought advice from healthcare specialists, social care professionals, the local authority’s quality improvement care home team and an independent consultant. This demonstrated the provider actively used external expertise to strengthen practice and outcomes.

Leaders showed strong oversight and forward planning when managing change. For example, the home was being extended, and robust plans were in place to ensure this was managed effectively. Staff had already begun to be employed in preparation for the opening of the new section, demonstrating proactive workforce planning and consideration of the service’s future needs.

Information was accurately recorded, securely maintained and shared appropriately with relevant professionals to support coordinated care. Overall, the provider’s governance arrangements provided robust scrutiny, clear accountability and access to a range of expertise. Leaders used these systems effectively to identify and manage risks, respond to feedback and learning, and drive continuous improvement. As a result, people experienced safe, well-coordinated care and benefited from a service that was responsive, continually improving and focused on achieving positive outcomes.

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.

Leaders maintained strong relationships with health and social care partners, enabling people to receive timely and consistent support. Information was shared accurately and without delay, ensuring external professionals always had what they needed to deliver effective input.

The service also worked in partnership with people’s relatives, where appropriate. A health professional told us, “I have experienced families being actively involved in their relative’s care and are included in discussions and decision-making including conversations around care plans to ensure the resident’s wishes, wellbeing and ongoing needs are understood and respected.”

The provider organised events to bring people together who had a shared interest in the service. For example, when they organised a ‘dementia day’, they contacted the Alzheimer’s Society and organised a dementia nurse specialist to attend and share knowledge. People were also brought together through events such as a summer carnival and celebrations such as at Christmas.

The provider had worked proactively to build meaningful relationships within the local community. This included established partnerships with local schools, encouraging regular visits from children, and close links with local church groups to support spiritual connection and reduce isolation.

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider actively engaged with research, projects and pilots with external organisations to improve the quality of care people received and contribute to wider learning in social care. The service participated in research through the South Central Regional Research Delivery Network (RRDN), worked with the Older People’s Mental Health team and contributed to oral care research. The service also contributed to a study seeking the views and experiences of older people and their families’ following periods of illness or deterioration, helping to inform future care provision. This demonstrated a commitment to using evidence and external expertise to strengthen practice and improve outcomes. The service also supported nurse students and was planning to take GP students, providing opportunities for learners to develop their knowledge of care home practice while bringing new ideas and perspectives into the service.

Innovation was evident in the use of technology to improve people’s experience and safety. The provider had won a ‘Tech for Care’ award due to the technology they had implemented to support care delivery. This included everyday assistive technology such as touchscreen activity systems, voice assistant and sensory devices. The provider also planned to continue this work and had planned an upgrade to the nurse call system to a digital solution, enabling timely responses while reducing unnecessary noise from building-wide alarms. Leaders were also exploring night-time acoustic monitoring to help staff respond to genuine need while minimising disruption to people’s sleep.

Leaders actively sought learning beyond the service by attending care sector events and contributing to care provider forums, where they built relationships, exchanged ideas and shared good practice.

Throughout the assessment process, the management team demonstrated a strong willingness to learn and develop systems in response to feedback. They had created a positive culture where staff were encouraged to reflect on what had gone well, what could be improved and what lessons could be learned. Learning was shared through supervision, team discussions and training refreshers, ensuring improvements were understood and embedded consistently across the workforce. Structured reflection promoted openness, curiosity and continuous learning, with a clear focus on improving practice rather than attributing blame. This helped ensure the service remained forward-thinking and focused on achieving the best possible outcomes for people.