Wavertree Nursing and 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 good governance.

This service scored 61 (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 manager explained they wanted to build a workplace culture based on respect, communication, trust and accountability. The provider had a statement of purpose which included information about the providers vision, however, there was little evidence of this having been shared with the team to ensure a wider understanding of the ethos of the organisation.

However, most staff said they felt involved stating ‘they all worked together as a team’.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The provider was not always compassionate and inclusive. Negative intelligence had been received detailing the provider’s lack of compassion and support toward staff, which had not been addressed effectively.

However, the manager told us they felt supported by the provider and was committed to ensuring a more inclusive culture by leading by example and having an open-door policy.

Staff stated both the manager and deputy manager were visible and approachable.

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

The provider had policies and procedures in place which guided staff through several ways they could speak up about any concerns they had regarding people’s care. This included speaking up via their supervisions, team meetings, by approaching the manager directly or following the provider’s whistleblowing policy.

Relatives knew how to make a complaint, and complaint forms were easily accessed within the reception area.

The manager created an open culture by encouraging people to speak up. The manager told us, “I am an open person, and I believe any changes start with me.” Staff confirmed they could speak up, one staff member said, “There is a new manager in place who says their door is always open if staff want to raise anything.”

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 manager took on board staff feedback. For example, concerns had been raised by night staff regarding a busy period in their shift and staff feeling isolated. In response to this, the manager created a new shift pattern which bridged the night and day shifts. This meant the busy period had more support staff and night staff could feel more integrated with the day team. This was working well and was positively received.

The manager informed us some staff had requested not to work specific days and this had been accommodated. Staff confirmed they had no concerns and were currently treated fairly. Staff meetings were regular and included discussing barriers to working together and how to overcome these. This demonstrated the wider staff team being involved in solution finding. An equality diversity and embracing culture policy was in place.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

A lack of oversight meant that some areas of concern identified during our assessment were not detected or addressed promptly. There was no system in place to report medication errors, this lack of system meant the provider did not have clear oversight to mitigate future risks. Medicine stock count audits, whilst identifying discrepancies, lacked actions to remedy concerns resulting in unresolved issues.

Care plan reviews were not effective. This contributed to care plans sometimes being inaccurate or out of date. The manager had recently introduced a more thorough care plan audit system; however, this would require time to fully embed into practice to ensure care plans were consistently up to date.

There was no robust system in place to ensure staff had been recruited safely resulting in unsafe recruitment practices. Processes were not in place to identify when staff had not received training in key areas necessary to meet people's individual needs. This placed people at risk of receiving inappropriate or unsafe care.

Some audits were not analysed for trends, themes and lessons learned to mitigate future incidents. The provider did not have some policies in place. This meant there was a risk of operational inefficiency caused by this lack of clarity. However, these were implemented once we requested them.

However, the provider had all the necessary current health and safety certificates in place, carried out regular health and safety checks of equipment and furniture.

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 provider worked collaboratively with other health professionals. Referrals to external health professionals were evident in people’s care records. Professionals we spoke to gave positive feedback. One professional confirmed referrals were timely and said, “I asked for them to get [person] to see a GP and they acted on that straight away.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

It was unclear how governance systems contributed to driving improvements. For example, some audits were either not completed or were not effective in identifying or addressing areas for improvement. Where improvements were identified, actions were not always taken in a timely manner to ensure sustained improvement. This contributed towards improvements identified at the time of our assessment. Training had also not been effectively monitored, which meant some staff were not up to date with their training. This placed people at risk of receiving care and support from staff who may not have the current skills and knowledge required to meet their needs safely and effectively.