Wensley House Residential Home

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• 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

Systems do not facilitate discussions about culture, service improvement or innovation. Staff told us they felt valued by the registered manager and provider, however neither had kept their knowledge up to date around their regulatory responsibilities. The registered manager acknowledged that audits and checks were not fully in place or embedded within the governance framework.

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.

Staff we spoke could tell us about the shared people first ethos and culture within the service. One staff member said, “The culture at the service is one of respect, compassion, and person-centred care. The core values focus on providing residents with dignity, promoting independence, and ensuring their well-being, while also fostering a supportive and collaborative environment for staff.”

However, staff could not identify any innovative plans for service development. A shared vision and strategy was not central to the day to day management of the service.

Staff said they were supported to promote equality and diversity within the team. Wensley House operated a sponsorship programme to employ staff from ethnic backgrounds and are supported within their sponsorships, to help facilitate successful inclusion and integration within a diverse workforce. One staff member said, “Wensley House to me is like a family, we all look after the residents as our family, and we all have different cultures, but we speak one language in Wensley House.”

The provider had not ensured there were processes in place to ensure the service was developed or changed in line with current national expectations of person-centred support. For example, ensuring dementia care was reflective of national guidance and good practise in areas such as environment or eating and drinking.

The provider did not routinely share with staff information such as a service development plan to seek their views and opinions, ideas or suggestions for improvement. They also did not seek people’s views on the management of the service and improvements that were important to them.

Staff told us they felt valued by the registered manager and provider. Staff received bonuses at Christmas as a reflection of their accomplishments as well as an interest free loan to support them through the festive period. Staff said the registered manager and provider were on hand and reflected the ethos of care provided to people. One staff member said, “It's a great experience dealing with the management; they treat the house like family, thus it's extremely simple to get in touch with them at any moment.” A second staff member said, “[Owner] calls every evening and at weekends to enquire about the residents and to see if everything is ok, or ask about updates on residents in hospital etc.”

The provider had processes in place such as team meetings and supervisions however these they could not demonstrate that these were facilitated regularly or that they were effective. Neither the provider or the registered manager had kept their knowledge up to date to ensure care was delivered in line with good practise or national guidance.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff all said they felt supported and listened to by the registered manager and provider. However, staff were not able to provide examples of where their feedback was listened to and acted upon. Staff all told us the registered manager was responsible and accountable but were not able to describe to us the different roles and responsibilities within the home.

Feedback from health professionals and relatives clearly indicated that the registered manager did not always delegate tasks or responsibilities to senior staff. However, staff did feedback during this assessment that the management team had listened to feedback and had undertaken implementing improvements and actions that positively influenced outcomes and overall performance.

The registered manager acknowledged that audits and checks were not fully in place or embedded within the governance framework. They were in the process of developing a new governance framework.

The registered manager told us they did not complete analysis of key risk areas, for example the frequency of falls, call bell response delays, wounds or weights. Analysis allows themes and trends to be identified and to then prevent recurrence. Frequent competency checks were not in place, care plan audits had not identified missing assessments. For example, risks associated with diabetes and how to support people’s dementia needs. Mental capacity assessments were completed, but lacked detail and best interest decisions did not consider other options to ensure restrictions were the least restrictive.

Audits had not identified the need to have appropriate training. The registered manager took immediate action to book this training.

Lessons learned were not embedded within the staff team to support staff development and service improvement. Staff, resident and relative meetings needed to be fully developed, planned and accurately recorded.

A service improvement plan was not in place at the beginning of this assessment to capture the actions and improvements required.

The provider and registered manager did not fully demonstrate a robust understanding of legislation or statutory requirements.

The provider did not have any independent reviews to monitor the service quality. This meant the registered manager worked with little scrutiny or oversight.

Improvement was required to ensure the environment met the needs of people living with dementia. For example, adapted crockery for mealtimes, ensuring the environment supported people finding their way around independently.

These areas were all incorporated into the service improvement plan but were a breach of regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

People experienced care that was joined up and delivered in partnership with a range of health care professionals and any necessary partners. People and their relatives told us that prior to moving into Wensley House a full and comprehensive assessment was completed. They were offered the opportunity to look round the home and meet other people and staff. Some relatives told us that they had moved people from another home which had recently closed, and the process of working in partnership had been a positive experience.

Staff told us they had good working relationships with most healthcare professionals. This included GP’s, district nurses, dietitians and specialist nurses, such as tissue viability and mental health nurses. Staff reviewed peoples care needs through daily staff handovers which were an opportunity to update the team on health appointments, referrals and any changes to people’s care needs ensuring actions arising were implemented.

Feedback from all healthcare professionals was positive and complimentary about the manner in which staff worked in partnership. One healthcare professional said, “I was involved in the recent closure of a local residential care home. Wensley House did not hesitate to go and assess those vulnerable adults who had safeguarding raised and accepted them into Wensley House. Wensley House worked well with the GP and I to support those residents. As a result, those individuals are well fed with home cooked meals, they have gained weight, they have been engaging in activities in the home. To compare their previous placement with now it's a remarkable improvement and I am so proud of Wensley house.”

All the staff and management were committed to sustain positive relationships with other health professionals to maintain good outcomes for people. Staff worked in partnership with key organisations to support care provision and joined-up care. Where necessary, the registered manager raised concerns or issues with communication within those networks promptly. For example, they were liaising with the local authority health team as they had identified gaps in the mental health and GP pathway which led to delays in people receiving care. This sharing of information with partners and a will to collaborate for improvement means the registered manager understands their duty to collaborate and work in partnership, so services work seamlessly for people.

Staff said they were given the opportunity to discuss ideas and receive feedback about significant incidents or events or about how the service was managed. For example, they said on one occasion senior staff were asked to document their best idea of how a shift should be run based on their hands-on experience. Although this was a positive example with senior staff, this did not seek the views of care team members, therefore was not wholly inclusive.

Staff spoken with however did provide an example of how improvement across the organisation had been prompted from our feedback. One staff member told us, “Since the CQC visit, some positive changes and improvements have been implemented. Meetings are now held more frequently, ensuring that all staff are well-informed and have a platform to share their feedback and ideas for improvement. All staff members [care, domestic, maintenance staff] are actively involved in serving food, which has improved the efficiency and quality of mealtimes. Meals are now being served in residents’ rooms 15 minutes before the scheduled time, ensuring residents receive their meals promptly and at the correct temperature.”

We found that improvements were needed to share information among staff formally through meetings. The service did not have clear records of lessons learned and how these were shared among all staff. For example, as the registered manager had not looked at themes or trends around areas such as falls, call bell response times, wounds or incidents, this had not been shared with staff to support learning. The registered manager did take action immediately, which was confirmed with staff as a positive development, to embed this within their meeting and daily huddles meetings. However, we have not been able to assess the impact this improvement has made on the learning culture within the service.