Wyndham 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

At the last inspection (publish 31 May 2018) the rating for this key question was Good. At this assessment the rating for the key questions has changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The provider had a variety of quality monitoring systems to support the management team to review and assess the service delivery at Wyndham House. However, we found these were not always effective and robust enough to assess, monitor and improve the quality of care people received. This was a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staff were mostly positive about the management of the home and the registered manager was positive about the support they received from the provider. The management team and the provider took our feedback on board and started implementing changes during the assessment. Such as addressing the concerns in relation to the carpet and reviewing the risk management related to the open staircase. A focused action plan was developed and shared with CQC and a schedule of regular engagement was proposed to discuss the progress of the actions the provider was taking to address our concerns.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Feedback from staff was mostly positive in relation to the management of the home. One staff member told us; “No complaints, supportive, they would consider it, if you put somethings forward”. Another staff member told us that the registered manager worked very hard and they recognised that the registered manager was under pressure and had a high volume of work they had to complete . The registered manager told us that the provider representatives who oversee the service were “Great”. They went on to say that they conducted weekly visits at least to provide support and oversight and support was also offered by peripatetic managers. The registered manager explained to us that they followed the visions and values of the provider. They praised the training department and support they received from the head office, for example with the admission process. They also said they valued the monthly meetings with the other managers as an opportunity for learning. The registered manager talked to us about the support in place for the team at the service through channels such as a suggestion box, various staff meetings, ‘you said we did’ actions and welfare checks on staff. The registered manager explained that recently things had been tough when they had needed to use agency staff who had not previously worked at the home. They explained that existing established staff see themselves as part of the Wyndham House family and if one is upset it has an impact on the others.

There was a schedule of quality assurance systems in place to support the management team review and assess the service delivery. The provider had oversight of the service. However, these were not efficiently implemented and robustly operated to monitor the quality of the care provided. The provider had not ensured actions were taken promptly and risks prioritised to implement improvements identified. Both the registered manager and the provider were very receptive to feedback and started implementing changes during the assessment They developed a focused action plan which they shared with us and will continue to update us on its progress every two weeks. The provider understood the requirements of the duty of candour. This is their duty to be honest and open about any accident or incident that had caused or placed a person at risk of harm.

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.

The service had a management structure in place with defined roles and responsibilities and staff were aware of their own attributions. Senior staff talked to us about their involvement of writing and reviewing people’s care documentation including risk assessments. We discussed with the registered manager the in-house process for auditing the care plans. The service audits a percentage of the care documentation every 3 months, and these audits were being delegated to the senior staff team to complete. The registered manager told us that once the care documentation audits were completed, the audits were reviewed by them, signed to confirm actions had been implemented and updated within the individual care plan. This system was not robust as the same staff who were responsible for writing the care documentation were also responsible for auditing them. The registered manager reviewed the audits but there was no clear evidence about how they were assured that the actual content of the care plan was in line with their expectations and the provider’s policies and procedures. Following our feedback the provider developed an action plan and shared it with CQC. A schedule of regular engagement was proposed by the provider to discuss the progress of their actions.

We found the provider did not have a clear and robust policy in relation to how they assess the risk related to open staircases. The provider had a schedule of quality assurance systems to support the review and assessment of the service delivery. The provider’s senior management team were carrying out a series of audits covering different aspects. This included a periodical CQC style mock assessment. Some of the concerns identified in December 2023 related to the care documentation, for example missing mental capacity assessments and best interest decisions and uncertainty about people's ability to consent, missing or overdue assessments including pressure care risk, falls and other risk and a large number of missed interactions. These were discussed in meetings and an action plan created. One of the actions from the May 2024 mock assessment was to review all care plans and to ensure risk assessments were implemented. We found some care plan reviews had been completed identifying similar actions to previous ones and to the concerns we identified. This meant that there was continuous risk that staff were not being provided with up to date information related to people’s risks and that further time was needed to ensure that these re-occurring concerns were being consistently addressed across all care documentation and changes maintained. The provider’s system of assessing staffing levels was not effective in identifying the concerns we did relating to dependency tools and call bell monitoring. Audits carried out in areas such as falls and behaviours of distress highlighted some concerns, however no actions were identified or taken. Systems of oversight of the service were not always effective and robust to assess, monitor and improve the quality of care people received. This was a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.