Wynhill Lodge Short Breaks Service

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 safe high-quality care.

The service was in breach of legal regulation in relation to good governance at the service.

This service scored 61 (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 clear shared vision, strategy, and culture that was centred on transparency, equity, equality, human rights, diversity, inclusion, and engagement. There was a good understanding of the challenges faced by people using the service and the needs of the wider community. Staff told us they worked in line with the provider’s values. One staff member told us, “I am aware of the provider’s vision and values. I ensure I work within them by maintaining a person-centred approach, treating individuals with dignity and respect, and following organisational policies and procedures. I also demonstrate these values in my daily practice by promoting equality, safeguarding people, and providing high-quality care and support.”

People using the service and their relatives provided positive feedback about the culture of the service and told us they had no concerns about the care and support they received at Wynhill Lodge Short Breaks.

Whilst the management team and staff demonstrated compassion and a commitment to ensuring people received safe, high‑quality care, this was not always supported by effective management oversight. Due to the concerns identified during the assessment which had not been identified through the provider’s own processes and systems we were not assured that senior staff and managers consistently had the knowledge or oversight required to ensure care was always safe and effective in meeting people’s needs. Although the management team were open and honest throughout the assessment and took immediate action in response to the concerns we raised, these shortfalls indicated that governance arrangements were not always effective in proactively identifying and addressing issues. This meant potential risks to people’s safety and wellbeing were not always identified or addressed in a timely way.

The provider had a positive culture that encouraged openness and transparency, and people felt confident their voices would be heard. Staff, people using the service, and relatives told us they felt able to raise concerns, risks, or complaints without fear of negative consequences.

Everyone we spoke with told us the registered manager was approachable and listened to concerns, and they felt appropriate action would be taken when issues were raised. One staff member told us, “I would feel comfortable raising concerns with the manager. The management team is approachable, and they create an environment where staff feel safe to speak up. I understand that raising concerns is part of keeping people safe and maintaining high-quality care.”

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.

Staff told us the management team treated staff equitably, and staff were provided with the same rights and opportunities. Staff had regular opportunities to raise concerns through supervision, staff meetings, and handovers between shifts. The provider also had an equality, diversity, and inclusion policy in place, which provided staff with clear guidance and supported fair and inclusive practice.

The provider did not always have effective governance systems in place to assess, monitor, and mitigate risks to people’s health and safety. Although a range of audits were completed, these were not effective in identifying the concerns found during the assessment, including issues relating to incident management, staff training, medicines management, risk management, care planning and risk assessments. Incident oversight was ineffective. The incident tracker recorded only one incident, and the registered manager was not aware of several incidents identified during our assessment. This meant it limited opportunities for learning and increased the risk of avoidable harm. Care plan and risk assessment reviews were also ineffective. Despite a keyworker system and review processes being in place, concerns relating to care planning, risk assessments, and Mental Capacity Act compliance were not identified. This meant staff did not always have clear guidance to deliver safe and effective care. The management team were open to feedback and took action to address the most serious concerns.

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. Professionals who were working in partnership all had positive feedback to share and told us the staff team worked with them in partnership. A relative told us staff worked well with them, they said “We have good relationships with staff. They always tell me if [person] a bit upset. It’s a beautiful place here. I wouldn’t let [person] come if it wasn’t. No problems at all. They [staff] know [person] really well and understand that they need their own space.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

The management team demonstrated a willingness to address the issues identified during the assessment. However, learning that should have been routinely embedded within the service was limited by a lack of effective auditing and oversight by the provider and management. As a result, opportunities to identify concerns proactively and learn from were not consistently in place. The management team told us they had plans to move from a paper care planning system to electronic and this would support them to improve the quality of people’s care plans and risk assessments.