Wharfdale Extra Care Scheme

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 service. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider had a statement of purpose which clearly outlined their values. From the inspection, the service was mainly achieving their values. However, some improvement was required regarding the documentation being person centred and identifying people’s goals.

Despite the values being part of the appraisal and induction process, staff did not always have a good understanding of what they were.

Staff and leaders described a positive culture at the service. Members of staff said, “We all get along well” and “We all felt confident in speaking up at team meetings and events”. They felt confident they could raise concerns with the service lead or senior manager of the scheme.

The results from the staff surveys for the extra care schemes the provider owned in Wigan was positive. A comment which had been extracted specifically in relation to Wharfdale Extra Care Scheme stated: “I'm extremely happy working at Wharfdale. My managers are approachable and very supportive with professional and personal issues.”

Leaders embodied the culture and values of their workforce and organisation and had the skills, knowledge, experience and credibility to lead effectively, however, there were concerns identified during the inspection which required better oversight.

We identified some shortfalls during the assessment which we would expect effective leadership to have identified. This included service assessments and care records not being detailed, risk assessments not always being completed or detailed and concerns relating to medicines management.

Most people and relatives felt the senior management were not visible at the service. However, in contrast people and relatives were extremely complimentary about the service lead who was in post, and a further service lead who was on maternity leave. Almost everyone we spoke with explained how they were visible, approachable and they felt they genuinely cared for them and the service.

Staff reiterated the points made by people and relatives. They described the service leads as “Compassionate”, “Kind” and “Visible”. A staff member said, “[Service lead] is kind and understanding [person]. This job means a lot to [them]. [They] are a brilliant team leader.” They felt overall the service lead had not been supported in their new role as the service had not employed a deputy service lead. Staff told us the leaders of the service were rarely on site and although they found them approachable, they were unsure of their involvement with the scheme.

Leaders told us they had recognised the amount of work placed on the service lead, in the previous service leads absence and had promoted 3 members of staff to support them in their role.

Professionals and stakeholders told us the service lead “goes above and beyond” for people and they ensure there is a “person centred approach to care.”

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

The provider had relevant policies and procedures in place for staff, people and relatives to raise concerns.

The service ensured regular supervisions, team meetings and staff surveys were being completed which were used to help drive improvements.

Staff demonstrated an understanding of safeguarding and whistleblowing processes. Posters in reference to raising concerns were in the staff room. Staff said they were able to speak out and share their views and ideas about the service. Staff told us the service leaders listened and acted on information which they shared. A staff member said, “I would have no concerns raising concerns I had if I felt something was not right. I know [the service lead] would act immediately and look to resolve the issue.”

The service had tenants’ meetings and satisfaction surveys which allowed people to provide feedback on their experience of the service.

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 policies and procedures which ensured they worked towards an inclusive and fair culture. They had an equality, diversity and inclusion policy in place and staff completed training. They also had policies and procedures for flexible working and for women affected by the menopause.

Leaders made reasonable adjustments to support staff to carry out their roles well.

Staff said they were treated fairly and equitably and had no concerns regarding staff being discriminated against.

Staff told us they were supported by the service lead and other leaders when they required flexibility with their working schedules.

The service did not always have good governance. They did not always act on the best information about risk.

The provider was identified as acting outside of their registration with the CQC. When this was raised with the registered manager, they provided an explanation and acted promptly to resolve the issues.

The service did not always have effective systems and processes in place. The service did not have a robust system to review people’s care records. They were missing a range of information which, according to the provider’s consent to care and treatment policy, should have been included. For example, we did not see evidence of a ‘Decision making tool’, a ‘Pain recognition tool’, ‘My review – person centred care plan’, a ‘Restrictive Practice Tool’, a ‘How to communicate with me’ document and a ‘Wills and wishes’ document. Furthermore, as outlined previously people’s care plans and risk assessments lacked sufficient detail, and some risk assessments were not included.

People’s various documents including their care plan, risk assessments and hospital passports did not always contain the same data. For one person, their hospital passport provided more information about how they were supported to communicate, than their care plan. The hospital passport for the same person did not contain up to date information, for example it outlined how the person was independent in terms of continence and medication administration when this was not the case. This posed a risk as hospital staff would assume the information was up to date.

Although medication audits were in place and regularly completed, we identified some running balance discrepancies which had not been identified as part of the internal audit. We did not receive the providers internal investigations into said running balance discrepancies, which showed a lack of oversight on the services behalf.

However, leaders and staff understood their roles and accountabilities within the service. The

service had some systems and processes in place which ensured information regarding incidents, accidents and safeguarding concerns had oversight and information was shared securely with others when appropriate. This included the registered manager attending a health and safety group quarterly which reviewed the services health and safety figures, including training data, how many risk assessments were in date and how many moving and handling assessments had been completed. Furthermore, the service lead was also responsible for some audits including apartment audits which reviewed the cleanliness of the apartment, whether medication had been administered correctly and the last time the person had bathed or showered.

Leaders were reactive to risks which they identified. For example, they had identified the service lead had a high proportion of work, as they did not have access to a deputy service lead, and thus had promoted 3 members of staff to support them. They were also responsive to feedback regarding the concerns identified with documentation regarding care records and medicines which they immediately started to make improvements on.

The provider had a comprehensive business continuity plan in place which ensured the safe and effective continuation of services in the event of disruption or emergency.

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.

Staff and leaders understood their duty to collaborate and work in partnership with others. They shared information and learning with partners and collaborated for improvement.

Staff and leaders were open and transparent, and they collaborated with all relevant external stakeholders and agencies. The provider worked closely with the local authority. The local authority and the provider collaborated on various matters, including building safety, for example, recently both had been reviewing fire safety procedures to ensure a consistent approach.

Staff and leaders worked in partnership with key organisations such as social services, housing associations, and community health teams to support care provision, drive service development, and create joined-up care. The provider worked closely with the local hospice and had raised funds for it. The provider also worked with a local food bank charity and sponsored local amateur sports teams, school productions and community events.

The provider hosted student social workers, health and social care students and provided work experience, ‘bring your child to work’ days and attended school career days.

People told us how they attended day centres frequently. One person attended a homeless support charity daily where they met with friends, ate food and played bingo.

The provider focused on continuous learning, and improvement across the organisation and local system.

The provider was involved in a recent research project with a local university regarding the recruitment and retention of staff within adult social care.

The service focused on continuous learning and improvement. They had systems and processes in place which allowed learning from incidents, complaints and safeguarding concerns. Staff told us leaders shared learning with them through various forums including team meetings.

The service had strong external relationships that supported improvement. For example, the service had a strong relationship with the local hospice which had enhances staffs’ knowledge and confidence in supporting people at the end of their life.

People were provided with opportunities to feedback on their care via residents’ meetings and via conversations they had with their carers or service lead who they felt comfortable speaking with.

Staff and leaders had a good understanding of how to make improvements happen. People, relatives, staff and leaders told us, and the service evidenced some good outcomes for people.