Wingates Residential 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 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 governance processes, identifying and making improvements and how accidents, incidents and complaints were managed.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had not always had inclusive leaders who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. The provider had not demonstrated they had the skills, knowledge and experience to lead effectively, and ensure the management they employed did so with integrity, openness and honesty.

At the time of our assessment the home had a manager and a deputy manager in place. The current manager had commenced employment at the end of March 2025, replacing the registered manager who had left earlier in the year. The deputy manager was new to the role. They had worked at the home previously, returning in January 2025 and being appointed deputy after the current manager had started. People, relatives and staff spoke positively about the current management team and commented on some positive changes having taken place over the last few months. However, it was apparent during the assessment period, prior to their employment leadership and oversight of the home had not been effective. Regulatory requirements had not been met, with no systems or processes in place to ensure these were done and/or to monitor compliance. The provider had not identified gaps in practice or documentation, or that checks to ensure the safety and effectiveness of the home and care provided were being done, either effectively or at all. The majority of evidence and documentation provided during the assessment, had been created from April 2025 onwards by the current management team, as they had been unable to locate previous records, or these had not been completed in the first place. This meant we could not measure or monitor compliance over time.The provider informed us as part of the factual accuracy process; audits pre-dating April 2025 were available for review. It was not made clear why this evidence was not provided during onsite visits or afterwards, when we had asked for additional evidence of auditing and governance processes to be sent to us, nor why the manager was unaware these audits had been completed. We did not review this additional evidence.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

We were provided with no clear information regarding the audit and governance process, for example what audits and monitoring were completed and how often. As such, we could not assess whether the management and provider had followed their policy and procedures. Audits which had been completed were not robust, as they had not identified any of the issues we found during the assessment process, such as the lack of certification for hoists and slings, issues with modified diets or issues with care plans.

Where audits had identified any shortfalls in practice, actions had either not been generated or if they had, been completed timely. For example, a medicines audit in May 2025 had identified a lack of guidance for staff to help them safely administer ‘as required’ medicines, such as paracetamol. This guidance was still not in place when we commenced the assessment in September 2025. Dining audits had identified concerns with how food was presented and served to people who chose to eat in their room for 3 consecutive months, with no improvements noted. Issues with infection prevention and control practices identified in May 2025, were still being identified as issues in August 2025.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Audits in use did not all include an action plan section for detailing how issues would be addressed. Where they did, issues identified during the audit had not always been transferred to this, so it was unclear what, if any, improvements had been made. We asked the manager where actions were recorded, and whether they used an overarching improvement plan, to ensure clear and effective oversight. They confirmed one wasn’t currently being used, nor could they explain why some audits had no action plan section. As a result, there was a lack of evidence the provider was identifying and addressing shortfalls effectively and driving improvements.

We found a lack of evidence to demonstrate learning from accidents, incidents and safeguarding was being considered and shared. Logs used to document accidents and incidents lacked detail and often contained no information about actions taken, outcomes and lessons learned. An accident analysis document was being completed, however, this just listed the date and number of accidents or incidents which had occurred during that time period, rather than an analysis of what had happened and an attempt to identify patterns or trends to prevent a reoccurrence.

The management of complaints was also variable. No records were available for review prior to April 2025, so we could not assess how they had been managed over the last 12 to 18 months and ensure the provider’s complaints policy had been adhered to. For complaints received since April 2025, the log used to document these lacked detail about the nature of the complaint, what action had been taken and outcomes. The provider’s complaints policy referenced there needing to be a documented audit trail, that detailed all steps and decisions taken. We found little evidence this was being done.We were provided with 1 example of the provider meeting their responsibilities under duty of candour. The manager had written to a relative who had complained, to discuss the concerns raised and their response to these.