Waxham House

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 since registration under the new provider. 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.

The service was in breach of legal regulations in relation to good governance.

This service scored 50 (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 did not have a shared vision, strategy and culture based on transparency,
equity, equality and human rights, diversity and inclusion, and engagement.

The management team had not always provided staff with effective leadership. Staff did not always feel listened to, and the culture was not open and inclusive. Feedback we received from staff suggested a blame culture had developed; this was corroborated through our observations. Some staff felt their individual needs were not fully understood or respected.

The culture of the service was not consistently person-centred. Some staff told us, “[There is a] culture of hygiene. Making beds and cleanliness comes over the caring of the residents” and “This attitude has taken over the forum of the new carers.”

In response to our feedback the provider told us they would work towards changing the culture and would implement a shared vision and strategy to achieve a positive culture throughout the workforce.
 

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively.

The provider and management team had failed to implement a positive culture. There were no recognised, shared values among the management or wider staff team.

The management team did not consistently demonstrate their capability to identify and address risks without delay. The concerns identified on this assessment as detailed throughout this report had not been identified or effectively managed until highlighted by inspectors. The management team did not always have the knowledge and experience to ensure regulatory requirements were met.

The new provider listened to feedback and responded to concerns we raised during the assessment.
 

People did not always feel they could speak up and that their voice would be heard.

The policies and procedures to support staff in speaking up and raising concerns did not provide all the information to support staff in doing so, for example, not all contact information of relevant external partners were available to staff. This meant the provider could not be assured that the management of the service actively promoted an open culture to ensure staff were informed and encouraged to speak up to organisations outside of the service where they had concerns.

Managers did not promote staff involvement or feedback in improving the quality and safety of the service. They did not encourage staff to speak up when things were wrong.
 

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 valued diversity and had a diverse staff team. Staff received training about equality and diversity, and the provider had policies in place relating to equality and diversity.

Management stated they would support and respect any considerations that may be needed for staffs’ individual needs.
 

The provider and leaders did not have clear responsibilities, 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.

The provider’s quality monitoring was not effective or robust. Audits had not always identified the shortfalls we found during this assessment. For example, the provider’s checks had failed to identify people were subjected to restrictions that had not been decided in line with the MCA. When shortfalls had been identified, the provider failed to consistently act without delay to drive improvement. For example, the provider failed to act and rectify fire safety shortfalls within the required timeframe.

The provider’s health and safety checks were ineffective. For example, the provider had failed to identify windows were not always restricted to prevent falls from height. Additionally, they had failed to identify this risk had not been assessed. This placed people at increased risk of avoidable harm. Bedrail risk assessments described, “Audit bed rails monthly to ensure there are no gaps to cause injury or death,” however, there were no audits being completed.

Systems and processes failed to ensure people’s records were always up to date and complete. People’s care records were incomplete or lacked detail. Some did not contain sufficient information for staff to manage specific needs or complex conditions safely. This increased the risk of inconsistent care and reduced staff’s ability to respond effectively to people’s needs.

The provider failed to meet their regulatory requirement to notify CQC of certain incidents affecting people’s health, safety and welfare. The registered manager lacked understanding as to what met the threshold of a reportable event.
 

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

There was a range of external health professionals involved in people’s care, such as GPs, district nurses and chiropodists.

Professionals informed us that where they had identified learning, the provider worked in collaboration with stakeholders to upskill staff and develop a greater insight to enable the provision of better support.
 

Managers did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not actively contribute to safe, effective practice and research.

Managers had not established an effective system to monitor the quality and safety of the service and to plan for improvement. Their monitoring systems had failed to identify the shortfalls we found during this assessment.

The new provider was open to the feedback we gave throughout the assessment and showed a willingness to improve when shortfalls were identified.