The New Wycliffe Home

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• 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 newly registered service. This key question has been rated 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.

During this inspection we identified a breach in regulation in relation to good governance.

This service scored 57 (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. However, further time was required for the provider’s shared direction and culture to be fully embedded and sustained.

The provider had experienced difficulties with staff culture and previous management of the service. This had had a negative impact on the quality of the service, and the provider’s vision and values to be fully applied. The provider was aware of this and whilst they had taken action and improvements had been made, they recognised this was ongoing to get to where they wanted to be. The staff team was becoming more stable with new permanent staff being recruited.

Overall, the current staff team was positive about the provider’s vision and values and showed a commitment in wanting to make continued improvement. A staff member said, “There's been a lot of changes since the new management took over. You used to do what you wanted, and it never mattered. Now you have to do it their way. Lots of staff didn't like it and left, but it is made the place better.” Another staff member said, “It's getting better and better, this new lot [provider] are trying hard, lots of staff have left, but then they needed to.”

The provider had 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 did so with integrity, openness and honesty.

The current manager was an experienced registered manager, who had previous experience of improving services. They were supported by 2 deputies of which 1 was also an experienced manager. The management team were supported by the provider’s quality team, a group of experienced and qualified managers in adult social care. The provider’s senior leadership team that included the managing director, operations director and the nominated individual (The nominated individual is responsible for supervising the management of the service on behalf of the provider) were all actively involved in the service, they visited the service regularly and had good oversight.

The management team had been open and honest with us before we inspected the service, keeping us informed of challenges they were experiencing that was impacting the quality of the service, and the actions they were taking to make improvements. Throughout the inspection process, they continued to be open, honest and transparent of where they were as a service, recognising they needed to make further improvements and embed and sustain the improvements they had made.

Staff were positive and complementary about the current manager and their management and leadership style. Staff told us the management team were always visible within the service, approachable and supportive. A staff member said, “I get supervision now, but I didn't use to. The first 3 years I worked here before the provider took over, I must have only had 4 supervisions, it's not like that now, we get them regular.”

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

Staff understood their responsibilities to report poor practices and ensure those in their care were treated respectfully and safely. Staff had been trained in safeguarding and whistleblowing and were confident with processes to follow if they needed to report any concerns.

Staff told us they felt able and supported to use the provider’s policies to report any concerns. A staff member said, “Management encourage staff to speak up and they always listen. The manager is helpful and quick to respond to concerns. They support staff and people that use the service.” Another staff member said, “Staff can speak up when needed without fear.”

Staff received opportunities via a survey to give their feedback about working at the service including what’s working well and any concerns.

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 that protected staff’s human rights and working conditions. This included a Flexible Working policy. Staff could also opt out of the working directorate, enabling them to work additional hours if they wished and this was monitored by the management team to ensure staff wellbeing. The staff rota considered staff’s shift and work pattern preferences.

The provider valued diversity within the staff team and demonstrated a commitment in supporting and valuing the staff.The staff team reflected the diverse needs of people using the service.

The provider had a commitment to develop and promote staff within the service. This was a approach to staff career development.

The provider’s systems, processes and procedures that included responsibilities, roles, and accountability had not been fully effective. The provider’s monitoring procedures had not identified all the shortfalls identified during this inspection.

We recognised the provider had experienced difficulties within the service that had impacted quality and safety, and they were working hard to make improvements. We were also aware the provider had been working with the local authority to make improvements and had a service improvement plan supporting them to further develop the service. However, we identified some shortfalls in the provider’s systems and processes that assessed, reviewed, monitored and mitigated risks. This put people at increased risk of harm.

The provider’s medicines audits and checks were ineffective. For example, the provider’s internal audits had failed to identify and or take effective, timely and mitigating actions, to make the necessary improvements in the safe management of medicines as described in the key question Safe of this report. This compromised people’s safety and put them at increased risk of harm.

The provider’s monitoring procedures of people’s care needs were not fully effective. Whilst care plans had been reviewed monthly, the provider’s review and monitoring systems and processes had failed to identify care plans and risk assessments were not sufficiently detailed or reflective of people’s current care needs. We were concerned of the time it was taking to make improvements and the lack of a risk based approach to this task. This put people at increased risk of harm.

The management oversight and monitoring systems and processes had failed to identify staff training needs. Whilst the provider advised us pre inspection, they had identified all care staff required retraining due to concerns about poor standards of care, the provider had failed to identify and take action of the training gaps this inspection identified. This meant people were at increased risk of receiving ineffective and inconsistent care, impacting their health and wellbeing.

There was no evidence the provider’s dependency tool had been used to determine people’s dependency needs and what staffing levels were required. The provider was aware before this inspection, of the continued concerns being raised about staffing levels. Whilst they had reviewed and improved staff development, the systems and processes that monitored the quality and safety of the service had failed to identify staffing levels were insufficient to meet people’s induvial needs and safety. This put people at risk of receiving inconsistent and unsafe care.Following our inspection, the provider submitted evidence confirming that they had completed their dependency tool. However, this did not alter our judgement that staffing levels were insufficient to meet the dependency needs of people using the service

The provider’s monitoring systems had failed to identify missing mental capacity assessments and best interest decisions that this inspection identified. A failure to meet the requirements of the Mental Capacity Act 2005 meant actions taken may not have been in the person's best interests, potentially infringing on their rights and well-being.

The food standards agency awarded a 3 star rating in May 2025. The provider’s audits and checks of food handling and expected best practice guidance, had failed to recognize the shortfalls identified in the food standards agency audit. This demonstrates ineffective monitoring procedures.

Systems and procedures to manage hospital discharges were found to be unsafe and ineffective. This put people at increased risk of harm.

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. However, this was identified as an area of further development and improvement.

Feedback from external professionals raised some concerns about partnership working. Whilst recent improvements were reflected upon, communication and collaboration in working together to support people to achieve positive outcomes needed further development.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. Whilst we saw examples of innovation to make improvements, this was an area for further development and required additional time to become fully embedded and sustained.

The systems and processes to ensure lessons were learnt from incidents, accidents and safeguarding needed strengthening. Whilst the manager told us discussions were held with staff, they advised this was informal and recognised it needed to be formal to be fully effective.

Systems and processes that monitored staff training had failed to ensure staff were equipped with the up-to-date knowledge and skills to provide a good level of care and support to meet people’s individual care needs.

The provider had recently developed a falls steering group meeting. This was a new internal initiative. This was a meeting attended by the provider’s registered managers across the organisation. This was a post fall huddle concept meeting, to discuss inconsistencies in documentation, lessons learnt and sharing of ideas in the management of falls. The manager told us they found this to be helpful and supportive.