Wentworth Court Care 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 at the service.

This service scored 62 (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.

Despite the concerns we identified on inspection, the leadership team were passionate about the service and committed to strengthening the governance processes to ensure people living with dementia consistently received good quality care and improved outcomes aligned with their shared vision, strategy and culture. One professional said, “[I believe the service provide safe care and support to people], above the standard of most dementia care provisions.”

Staff and relatives generally described the service as having a positive culture and environment. One relative said, “The staff all seem to know what to do. There’s always an active ‘buzz’ about the place. Lots of smiles.”

Leaders did not always have the oversight or systems required to consistently identify, recognise or escalate concerns within the service. Gaps in internal processes meant that risks were not always reliably spotted or acted upon. Although leaders created an inclusive culture, their understanding of the service did not always translate into effective governance or reliable assurance which limited their ability to maintain safe and effective oversight.

The registered manager was new in post and was working towards developing a more effective governance process, so they could be more aware of the issues and priorities for the service. Following on from the concerns we raised on inspection, the new registered manager told us they were now accessing additional support to aid their development within their new role.

People and their relatives gave mostly positive feedback and told us that leaders at every level were visible and available. One relative said, “[The] manager has an open-door policy…they’re pretty amazing – pretty amazing really.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The service had an up-to-date raising concerns, freedom to speak up and whistleblowing policy and procedure. Staff demonstrated an understanding of whistleblowing and could explain what they would do if they needed to escalate concerns about poor practice. A staff member told us, “I feel confident to speak up and know that if I report something it will be taken seriously and investigated.”

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 home had an equality, diversity and human rights policy and procedure, and staff received training in this area. The staff team at the home was diverse, and we found no evidence of bullying or discrimination. Staff told us they felt valued and respected by their colleagues and management team. One staff member said, “The staff are brilliant - it is so diverse here. Everyone gets on. It is a lovely place to work.”

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.

There was a governance structure in place to support the provider and management team to undertake their roles. However, the governance systems we saw at the time of inspection were under developed and did not drive sustainable improvement. The providers current governance systems had not been implemented or operated effectively to monitor the service and identify the shortfalls we saw in relation to medicines at this inspection.

Audits were inconsistently completed, and lacked structure, oversight and follow through. For example, a lack of recent audits in relation to medicines meant that the service had not identified the concerns we found in relation to medicines. medicines policies and procedures were in place at the home, staff were not following these. A system of medicines audits was in place at the home; however, staff told us that over the last few months they had not had time to complete these audits. The absence of routine and meaningful care plan audits meant that the service did not identify they had missing information for people with a specific health condition. Audits were completed but were not used meaningfully. This absence of audits and oversight placed people at risk of harm.

Effective governance processes to learn and improve from incidents and accidents had not been operated effectively. Incident reports, specifically in relation to falls had not been consistently analysed or reviewed. This meant that we could not be clear whether measures had been put in place to reduce the risk and minimise the potential for reoccurrence.

The registered manager was new in post and was working to understand their responsibilities, so they could, more effectively, act on the best information about risk, performance and outcomes. We shared our concerns about the lack of effective governance with the provider. Although they had not, through their own systems, identified the shortfalls we found on inspection, they responded to our feedback and put further measures in place to offer the support, guidance and expertise required to make the necessary improvements. This involved the recruitment of an external professional to offer clinical supervision to the registered manager and additional support at governance meetings on an ongoing basis. We spoke to a staff member who recognised the shortfalls but felt confident about the improvements which could be made to the governance. They told us, “I know there are things missing. We are aware and I have been aware. The crossover was difficult between the old registered manager as there was no handover. I can see that the lack of handover has had an impact, but I feel confident that it will be resolved. The gap in the middle has caused a shortfall, but I have every confidence that we are going to sort it out. I have every confidence in the new registered manager. She is brilliant.”

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 people, other organisations and communities to achieve the best possible outcomes for people. They worked in partnership with a range of stakeholders within the local community, including health professionals and the local authority, to support people’s care and wellbeing. A healthcare professional told us, “Wentworth Court Care Home provides a very good standard of care for [people], many of whom have complex conditions and needs. The team works collaboratively and effectively with [professionals], demonstrating a strong commitment to high standards of care and communication to ensure high-quality, person-centred care.” The registered manager told us, “We have a good relationship with external agencies, GP surgeries and schools.”

The service provided examples of how they were embedded in the community and considered a valued partner by others in the community. A staff member told us, “At Christmas we have choirs and children coming in to sing carols. For the last 3 years we have been chosen by [a local business] for them to donate presents to [people at the home].” The general manager also told us, “We go to [a local secondary school] and I talk to the year 12 children about careers in health and social care. The children come in here as well… We are in the middle of the community…we are part of that community.” This was corroborated by a professional who told us, “The home has a partnership with a [local sports club}. The partnership [they] have with schools is [also] really good.”

The provider had a strong focus on innovation and improvement across the local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The home had recently worked with their local integrated care board (ICB) to create short films which are now used across the county as a training tool for staff working with people with dementia. The films required staff to be filmed in their day-to-day work supporting and engaging with people living at the home. A professional working for the ICB told us, “[The home] worked with [a local university]. [The process went] through the ethics committee. [The home did] a lot of work around consent. They have been absolutely brilliant and open to learn. They took everything on board and are committed to making a difference…They were working with specialist dementias professionals…The films have been invaluable. Their openness to constructive feedback has been so positive. It has been a really positive experience.” The general manager told us, “To say you are a dementia specialist home, you have to do something to warrant that. You have to demonstrate something a bit more. Working with the university and other professionals, it really highlights the constant need to learn, continually improve and keep moving. With people with dementia you have to keep moving.”

The provider showed a strong commitment to ongoing learning and had also started to look at how they could further support people, relatives and staff, and had started planning talks within the home as a dementia resource. The provider told us this would involve inviting family members and professionals from different fields to share knowledge and experience to improve the outcomes for people living with dementia within the home and the wider community. The general manager told us, “The important things is not to stand still. I want to know that the care provided in the whole county is good. I want to share knowledge and experience and information and as part of good practice.”

Managers and leaders at the home welcomed feedback and could demonstrate what action had been taken in response. A professional told us, “Wentworth Court are always committed to learning and development opportunities and reflective practice…They strive to provide excellent dementia care and are open to constructive conversations when this is seen to fall short.”