Wendleberrie 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 Requires improvement. At this assessment the rating has remained 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 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 clear vision for the service and the culture they wanted to promote. People, relatives and professionals spoke positively about the management team and the support they received.

Staff described a positive culture where people worked together to provide good quality care. Learning was promoted through daily handovers, staff meetings and updates on the electronic care system.The provider had a clear vision for the future, including plans to grow and develop the service. However, further work was needed to strengthen the strategic direction for governance and quality assurance to ensure effective oversight and support continuous improvement.

The provider acknowledged this feedback and told us they would strengthen leadership support and governance arrangements. This would need to be embedded in practice.

Leaders did not always provide effective oversight to ensure issues were identified and addressed promptly. Governance and management support needed to be strengthened.

Feedback from staff, people and relatives showed leaders were caring, approachable and inclusive. Staff told us they felt well supported, and leaders were open to feedback throughout the assessment. A relative told us, "I have total trust in them."

However, the Deputy Manager (person in charge) was responsible for a wide range of operational and management duties, this did not support them to maintain effective oversight across all areas of the service.

We also identified examples where greater leadership oversight would have been beneficial. For example, continence products were stored on bedroom floors and on top of wardrobes, which did not support a tidy and homely environment. We also found an example where records were not consistent. One person's call bell assessment stated they were unable to use the call bell due to memory difficulties, while their Mental Capacity Act assessment recorded that they had capacity and there was no supporting care plan explaining their needs.Some relatives also told us communication and involvement in care planning could be improved.

The provider acknowledged these findings and told us they would strengthen management support. This would need to be continued and embedded in practice.

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

The service promoted an open and transparent culture. Staff told us managers were approachable and encouraged them to raise concerns, ideas and suggestions for improvement.

Regular staff meetings and supervision gave staff opportunities to discuss issues and raise concerns. Staff told us they felt listened to and were confident their concerns would be taken seriously.

Relatives also told us they felt comfortable raising concerns with staff and the management team and found managers approachable and responsive. A person told us, "I know who to complain to, who runs the place."

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 told us they were treated fairly and with respect by managers and colleagues. They said they felt valued and supported in their roles.

There was no evidence of discriminatory practice. Staff understood the importance of treating people fairly and respecting individual differences.

The service had a stable and experienced staff team, with many staff having worked at the home for several years. Low staff turnover helped provide continuity of care and maintain positive relationships with people and their relatives.

The provider had systems in place to monitor the quality and safety of the service, including audits and management checks. However, these were not always effective in identifying and addressing issues.

During the assessment, we found some care records and risk assessments had not been kept up to date. For example, falls risk assessments had not always been reviewed following significant incidents.We also found gaps in Mental Capacity Act documentation. Records did not always demonstrate that decision-specific assessments and best interest decisions had been completed or clearly recorded where required, including for CCTV monitoring and some shared room arrangements.

We identified gaps in the recording and follow-up of employment references during our review of recruitment records.We also found that compliance with mandatory training had been low in several key areas. Although the provider took action during the assessment to improve completion rates, this had not been identified and addressed promptly through their governance processes.

This showed quality assurance systems were not always effective in ensuring records were accurate, complete and up to date. The provider acknowledged our findings and told us they would strengthen their auditing and monitoring processes. This would need to be continued and embedded in practice.

The provider worked well with health and social care professionals to support people's needs. Staff told us referrals were made appropriately when people needed specialist advice or support.

Management took part in local care provider forums and registered manager networks to share learning and keep up to date with good practice.People were encouraged and supported to remain involved in their local community, including visiting local amenities and taking part in activities that helped maintain social connections.

The provider had systems in place to monitor the quality of the service, including audits, incident reporting, feedback surveys and safeguarding processes. However, they could not always demonstrate how information from these systems was analysed and used to identify trends, share learning and drive improvement.

The provider gathered feedback from people, relatives and staff through surveys and meetings. However, it was not always clear what actions had been taken in response to feedback or how learning had been shared.

The provider had a service improvement plan and was investing in the future development of the service through building works. However, the improvement plan did not clearly identify actions, responsibilities or timescales. The provider could not demonstrate a clear plan for managing the impact of the building works or how outstanding fire safety actions and associated risks were being monitored and progressed.