Winscombe 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. T 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. The provider failed to ensure systems and processes protected people from possible harm.

This service scored 57 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Although staff were complimentary about the culture within the service and its leadership, Our observations and our review of the providers audits and vision did not demonstrate a truly person-centred culture. As a result of our feedback, the registered manager provided us with evidence staff had been booked on additional training in respect of insulin management, moving and handling and additional training in respect of The Mental Capacity Act 2005. Staff provided positive feedback about the service and told us they enjoyed working there. One member of staff commented, “I feel supported, well trained and I enjoy working with people here”.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. There was limited evidence of strong oversight or accountability to ensure improvements were being driven forward. Systems and processes designed to monitor care delivery and support staff were not being effectively implemented. Supervisions were not routinely carried out, meaning staff were not consistently supported, guided, or held accountable for their practice. In addition, there was no clear process in place to follow up on training to check whether staff had understood and embedded their learning into daily practice. This weakened the service’s ability to ensure staff were competent and confident in delivering safe, compassionate care. The absence of capable and compassionate leadership had a direct and negative impact on the culture of the service and the wellbeing of the people living there.

The registered manager told us staff had lots of different ways to speak up if they needed to. There was a whistleblowing policy in place which all staff had access to. The registered manager gave us examples of how they had listened to staff concerns and taken action to improve the service. Staff consistently told us they felt support by the leadership team and commented positively on their caring attitude.

The registered manager told us about systems in place to support staff with their wellbeing. If staff needed reasonable adjustments to working patterns this could be considered. The provider recognised that support for staff was important for care delivery so tried to provide staff with resources for positive wellbeing. Staff told us they received the support they needed to do their job.

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. We identified significant concerns in respect of safe care and treatment, safeguarding, person centred care, good governance, need for consent, notification of other incidents and staffing. The provider’s quality audits did not recognise the areas of concern we found during the inspection meaning the provider’s systems and processes were not able to effectively assess, monitor and mitigate risks relating to health and safety and welfare of people. This had put people at significant risk of harm.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information with partners and collaborate for improvement. One professional spoke positively about the relationship between themselves and the leadership team at Winscombe and told us they were enthusiastic to improve people’s experience. They commented, “The management team have all attended the Huntington’s Disease Association training and are booked to attend the European HD Network annual conference this year. They have also developed networks with the local Huntington’s Disease Association local branch and attend support meetings.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. Although the provider was motivated to learn and improve the service, their overall ambition was limited by their lack of knowledge and understanding of current best practice in some aspects of care assessment and delivery. Whilst the provider had identified areas for improvement, they governance systems failed to properly investigate matters, put robust action plans in place and consistently drive improvement.