Wyndham House 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 inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.The service was in breach of legal regulation in relation to governance at the service. 

This service scored 36 (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. They did not always understand the challenges and the needs of people and their communities. The service had a statement of values and aims, but these had not been consistently implemented in day-to-day practice. Staff told us the manager was not always approachable, and they were unclear about expectations and priorities. Despite the high incidence of falls within the service, we could not see that there was a robust culture around risk assessments and learning from incidents. Staff told us that they felt a disconnect with the leadership, and that this needed to improve.

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. Governance systems had failed to identify the full extent of the shortfalls we found. The manager was not always able to demonstrate oversight of people’s individual needs or training compliance. We could not see that there was a consistent approach to the management of incidents and accidents, and with very severe incidents, the provider had not completed root cause analysis or implemented an action plan to drive change.

People did not feel they could speak up and that their voice would be heard. Staff told us that complaints about workload and fear for residents’ safety had been ignored for a long time. Staff felt that the manager’s closed door created a barrier, and some did not feel confident approaching them. Some relatives we spoke to told us they knew how to complain and that the manager and deputy did act. Records of complaints did not clearly indicate the outcome and actions taken.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for the people who worked for them. We found the provider had a workforce with significant diversity, including a large proportion of agency and overseas staff. However, there was insufficient oversight of the experience and well-being of these staff. Permanent staff raised concerns about the disproportionate burden placed on them due to the need to supervise and guide agency workers. We found evidence of language barriers between some agency staff and residents, which affected both care quality and the dignity of the people receiving care. The provider had not taken sufficient steps to address this to ensure all staff could communicate effectively with residents.

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. The provider had multiple data collection systems, including incident records, audit tools and care records, but these did not consistently translate into meaningful action. Falls data was collected, but this did not lead to effective interventions for people with a high frequency of falls. Medication audits had not identified the errors we found during inspection. Care plan audits had been completed but had failed to identify the inconsistencies and gaps in documentation. Governance systems had not been effective in identifying shortfalls and driving improvement.

The provider did not always understand their duty to collaborate and work in partnership, so services could work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. We found that while the provider made referrals to external health professionals, the follow-up and integration of outcomes into care planning were inconsistent. District nursing and SALT involvement were noted, but outcomes from these engagements were not reliably documented. The provider had not always engaged proactively with the local authority or other commissioning partners to share learning or drive improvement. We did hear from one external professional who commented positively on the service’s responsiveness to telephone contact. However, the overall picture was of a service that had not embedded effective partnership working into its governance and care delivery.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. Despite a training matrix and incident recording system being in place, data was not consistently analysed to drive improvement. The training matrix identified poor training completion rates, yet there was no evidence that this had triggered an escalation or structured improvement plan. Analysis of incidents over 3 months showed a high proportion of falls were unwitnessed, indicating systemic supervision deficits that had not been addressed through learning. The provider’s post-incident action plans were largely generic and did not demonstrate that root causes had been identified or that specific, measurable interventions had been implemented. We did not see that lessons from incidents were shared formally through team briefings or supervision.