Wrenbury Nursing 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 remained 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 71 (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 registered manager promoted an open and honest culture. Staff described a positive culture at the home, where they worked well as a team. The registered manager worked with staff to develop a shared direction, based on shared values. Staff told us they were supported to raised and report any concerns. Various records, including meeting minutes demonstrated they guided and encouraged staff to meet certain expectations. They shared several examples of good outcomes for people, which reflected the shared approach to the care and support provided.

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 registered manager had been in post for several years and provided visible and experienced leadership with a strong understanding of the home and people living there. They were supported by the provider and a clinical lead and were passionate about providing safe and effective care to people in a caring environment. Overall, people and staff were very positive about the leadership within the home.

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

People, relatives and staff told us they felt able to speak up or raise any concerns if needed. The provider had relevant policies to support and guide staff in how to raise any concerns. The registered manager had an open-door policy and was accessible to people and staff. A relative commented “(Registered manager) would listen and try to support us, she sorts it.”

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 a policy to support equality and diversity in the workplace and staff had undertaken relevant training. They had recruited a diverse staff team and feedback indicated staff were treated fairly. The registered manager worked towards an inclusive approach. A staff member told us, “It’s a good workplace.”

The provider had governance systems in place to check the quality and safety of the service, but they were not always fully effective. Where identified, the registered manager took actions to monitor and improve practice. However, we found some minor gaps, such as aspects of recording relating to care planning and risk assessments, and unlocked cupboards. We also found 2 mattress settings were not set correctly but checks had not identified this.

The registered manager had made changes to their IPC auditing processes following an external audit which had identified some required actions. They had an ongoing improvement plan in progress with several actions already completed. The registered manager was responsive during the assessment and took some immediate actions in response to our feedback.

The provider had not ensured CQC was notified of all incidents as a legal requirement. Whilst in the main the registered manager had notified us appropriately and had reported incidents to the local authority, they had not identified some incidents as notifiable to CQC. They confirmed they would ensure these were reported in future.

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.

The registered manager had built effective working relationships with various health and social care professionals. Partners told us staff worked well with them and regular meetings were held.

Links to the community were being further developed by the new activity co-ordinator, with visits from various community members and plans for outings including walks in the local areas.

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.

Through sharing the results of their latest survey, the registered manager demonstrated they were, “Always open to any new ideas and will actively listen to any concerns you have and aim to improve.” Where an external audit had been undertaken which required an action plan, they shared this with the staff team, to support learning and improvement.

A visiting professional told us they had seen “Lots of good practice,” and felt managers were very self-reflective. The provider had been nominated for a national award in relation to aspects of care and staff practice.