Wisteria Care

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.

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

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. The registered manager told us their aim for the service was “To provide high quality care to as many people as we can, for people to be safe and well supported.” The registered manager told us there were some improvements required to the culture of the team and they wanted a “Nicer culture for staff.” They had been working with the staff team to achieve this. They acknowledged there was work to do and told us they were committed to achieving this.

We received some mixed feedback relating to staff morale. Some staff were positive and thought it was a good place to work, others felt they were not always listened to.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always have the skills and knowledge they needed to operate all aspects of the service effectively. The registered manager was also responsible for overseeing another of the providers services. This impacted on their ability and capacity to manage the service due to its size, location of services and the concerns identified. The provider gave us assurances they were reviewing this and had plans in place to ensure the registered manager was supported. The registered manager told us they were supported by the provider and management team.

The registered manager was open and transparent throughout our assessment process. The registered manager was compassionate about the people they supported and the staff team, they were committed to making improvements to the service.

Most people and their relatives spoke positively about the management team, saying they had good relationships and could make contact when needed. We received some mixed feedback from staff relating to how supported they felt. The registered manager gave examples of how they were working with the staff and engaging them in having opportunities to provide feedback.

One professional told us, “[Name of registered manager] is responsive, they make appropriate referrals and will look into things.”

The provider had created a culture where staff felt able to speak up and raise concerns.

The provider had a whistleblowing policy in place, not all staff were aware of this, however most staff were able to describe how they would report concerns externally. We discussed this with the registered manager who provided evidence they had emailed all staff the whistle blowing policy and procedure prior to our assessment. We also reviewed staff supervision notes where safeguarding and whistleblowing had been discussed and staff acknowledged their understanding.

One staff member told us, “I feel very much empowered to speak if ever I have concerns and I am listened to and feedback is always given.” Another staff member commented, “I feel empowered to speak up if I have any concerns. I understand the safeguarding and whistleblowing procedures within the organisation and feel confident that I can report concerns to my manager without fear of negative consequences.”

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.

Most staff told us they were treated fairly and equally. The registered manager gave examples of how they supported staff with reasonable adjustments when needed. Staff received equality, diversity and inclusion training.

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.

The governance systems in place were not robust to ensure effective oversight of the service. Although monitoring arrangements existed, they did not detect the significant issues we found. This meant the provider was not consistently assured risks to people were being appropriately assessed, recorded and monitored.

Care plans and risk assessments were not consistently up to date or sufficiently detailed. Important information and risk assessments were missing. We identified shortfalls in medicines management and the application of the Mental Capacity Act 2005. Whilst actions were taken once we raised these issues, they had not been identified through routine checks. Therefore, governance systems did not provide reliable assurance, and leaders relied on reactive responses rather than proactive identification of risk.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The provider worked in partnership with people, relatives and other professionals to support care delivery.

We received some mixed feedback from professionals relating to the service. Staff demonstrated an understanding of working with families and external professionals.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

Leaders demonstrated a willingness to learn and took prompt action to address issues raised during the assessment. The registered manager gave us examples of how they had taken on feedback from professionals and made improvements to the service, this was evident in staff supervision records where more details were recorded. The registered manager told us they used feedback from their twice yearly people and relatives survey to support improvement. They had an action plan in place following the last survey in September 2025. One of the actions from the survey was to monitor travel time for staff, action had been taken to address this.