Archived: Wolverley Court Residential 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 good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.The service was in breach of legal regulation in relation to the governance of the service.
 

This service scored 32 (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 clear, shared vision, strategy, or culture based on transparency, equity, equality, and human rights. Leaders did not foster a learning culture and missed opportunities to identify and address shortfalls. They did not develop or communicate a clear direction for the service, and there were no regular discussions to align staff with the service’s aims. The provider failed to recognise language used in care records was labelling and judgemental. One person was described as having challenging behaviour, staff had not acknowledged the need to identify underlying causes and what support was needed. This demonstrated a lack of inclusive practice and awareness of person-centred care.

The provider did not have inclusive leaders at all levels who understood the needs of the people they supported or reflected the values of their teams and organisation. Leadership lacked the right skills, experience, and credibility to guide the service effectively, and did not lead with honesty, openness, or integrity.
Staff reported that they did not receive an induction when they began working at the service and lacked access to regular, ongoing support and professional development. Leadership and management within the service were not effective. Systems to identify and drive improvements were not in place, resulting in a lack of oversight. However, people and relatives we spoke with did not raise concerns with us regarding the leadership of the home.
 

The provider did not promote a culture where staff could challenge practice and drive improvement. Staff did not challenge when they saw practice, such as moving and handling techniques, that they knew were unsafe. There was no evidence of how complaints were recorded, investigated or lessons learned shared with the team. However, we saw a record on 1 person’s care records which recorded the complaints procedure had been explained to them.

We were unable to assess if the provider made sure the staff team was representative of the population using the service as information was not available for us to review. Leaders had not always made suitable adjustments to meet people’s protected characteristics. For example, where people required specific equipment, this was not always available or in good working order. We could not assess if staff had been suitably trained in equality and diversity to help them understand about protected characteristics, bullying and harassment as there were no training records available for us to review.

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.
The provider did not have systems in place to ensure all areas of the service were audited so shortfalls could be highlighted and addressed. One audit was a photocopy of a completed ‘Quality Assurance Audit’ from a different service, with a label placed over it and ‘Wolverley Court Care Home’ handwritten on top. We were not assured that this audit related specifically to this service. One section of the audit stated, ‘service users cultural and spiritual needs are planned for and addressed in their person-centred plan, and these are understood and observed by staff’. This had been ticked to indicate the service was compliant with the statement. However, we found care plans did not contain any information regarding people’s cultural and spiritual needs. There was no evidence of medicines or care plan audits taking place.
The provider failed to adhere to their statement of purpose. A statement of purpose is a legally required document which outlines the service’s aims and key operational details. Our review found several discrepancies. For example, the document stated that ‘all medications would be stored in locked cupboards, preferably in residents’ rooms’, we found this was not the case, as detailed in the safe section of this report. The statement also claimed, ‘meals would be nutritious, varied, and reflective of residents’ diverse ethnic backgrounds, with residents involved in menu planning’. However, we found no fresh food available for meal preparation, only ready meals stored in the freezer. The kitchen showed no signs of active food preparation or resident involvement. Menus on display were copied from another service, meaning residents had not taken part in planning meals, and their preferences and dietary needs had not been considered." The provider stated they would issue three-monthly questionnaires to service users, stakeholders, and visitors to monitor and improve the service. A relative and healthcare professional we spoke with confirmed they had not been asked for feedback.
The provider did not ensure staff had a clear understanding of the needs of people using the service, which reflected a lack of effective leadership and oversight. At the start of the assessment, inspectors asked staff to describe the needs of individuals living at the service. Staff gave only basic information, and in some cases, shared incorrect details. For example, 1 staff member said a person had a pressure sore, but we found no records to support this. When asked to clarify, the staff member named someone else, however, their records were also incomplete. There was no care plan or risk assessment. This demonstrated that the provider had not ensured accurate, complete, and contemporaneous record-keeping, nor had they equipped staff with the knowledge required to deliver safe and effective care. These failings indicate poor leadership and a lack of accountability in maintaining service quality.
The provider failed to consistently notify the CQC and the local authority of safeguarding incidents. This showed they had not acted in an open and transparent manner.
 

The provider did not understand or fulfil their duty to collaborate and work in partnership with others, which prevented services from working seamlessly for people. They failed to share information or learning with external partners and did not engage in joint efforts to improve care. For example, when medicines were running low, the provider lacked effective systems to communicate the urgency to dispensing pharmacies. Some healthcare professionals reported difficulty contacting staff by phone. Additionally, staff did not actively support people to engage with the wider community, placing individuals at risk of social isolation.

The service 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.
The registered manager did not support a learning culture within the service. Systems were not in place or robust enough to drive quality and safety improvements. Actions were only taken following concerns being raised by the local authority, fire service and the Care Quality Commission.