Wytham 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.

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.

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.

Staff and leaders demonstrated a positive, compassionate, listening culture which promoted trust and understanding between them and people using the service.

There was a shared direction and culture, staff, professionals and people/relatives all commented on positive changes over the last several months.

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.

Staff felt safe and supported by leaders, who were visible and led by example. We heard, “I have direct access to my manager, and I can ask anything I want” and “Managers have come to the floor to assist me which is strange with as from my previous experience I have not had this support before. I can talk to [the manager] where I think I think I might need encouragement. [The manager] has given me ideas, and we work as a team.”

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

Staff knew who to approach if they needed to speak up and told us they felt respected, and Wytham was a positive place to work.

Processes in place provided staff with opportunity to speak up if they had any concerns. Staff were aware of who they would speak to if they had any concerns around culture and practice at the service.

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 had completed training in equality and diversity.

Staff told us they felt supported in their role, if they had any concerns they would be acted on. We observed a positive culture during our onsite inspection. New staff were made to feel welcome at the workplace.

The provider had clear responsibilities, roles, systems of accountability and good governance systems in place. However, governance systems were not always utilised to identify concerns found during the inspection.

Leaders told us risks were analysed in the monthly clinical governance meetings. Following the inspection, we received a clinical governance meeting minute document. Although the meeting documented action taken, there was not always a target date, or person responsible for ensuring the actions were complete. We found that clinical meetings and clinical audits identified concerns around pressure sores and bruising. Information had not always updated within peoples care planning or risk assessments. Clinical meetings and audits did not contain all incidents that had taken place, or document the action taken to mitigate the risk.

Some systems and processes required further development, for example, the auditing of care plans. Care planning audits had not always followed up on required improvements as they did not contain all actions or identify information had not been updated to reflect the persons current needs. The provider told us they would take immediate action to review their current systems and documentation in place following the inspection.

Audits of the service were completed regularly. Audits which required a scoring, did not always accurately reflect the score when reviewing the comments within the audit, and there were no additional comments or actions documented in order for the service to follow up on.Some actions from audits were not identified on the service improvement plan in order to ensure improvements could be made. The previous improvement plan contained completed actions, however, we found information in peoples care planning was not accurate despite being documented as achieved.

Data and notifications were consistently submitted to external organisations as required.

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 were open and transparent, and they collaborated with relevant external stakeholders and agencies. We heard positive feedback from professionals about how the service updated them about outcomes from safeguarding or actions they had taken to keep people safe.

Professionals told us there had been recent improvements to the service around risk, the service was more protective in how they responded to and managed risk. Staff were knowledgeable and the service is forthcoming and organised. how communication had improved over the last several months.

Staff and leaders work in partnership with key organisations to support care provision.

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. There were processes to ensure learning happened when things go wrong. Leaders encourage reflection and collective problem-solving.

There were processes in place for learning and improvement. Investigating incidents was not always carried out in a timely manner to ensure learning was implemented, however, where these had been carried out, there were good examples of lessons learnt following some concerns found in audits.