Waverley Care 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

We looked at all quality statements for Well-led at this assessment. The service was not Well-led. The provider failed to operate safe and effective governance systems, and processes in place such as, audits were incomplete or of poor quality. The provider did not independently identify risk which impacted on people’s safety and welfare and placed people at risk of harm. As there was limited oversight of accidents and incidents, this meant the provider could not be open and transparent when things went wrong. The provider was working with stakeholders to identify and address areas for improvement; however, actions were not being completed and there was little progress with the action plan following our last inspection. During, or shortly after, our assessment the manager left the organisation. We found concerns about governance systems, which resulted in a breach of the legal regulations.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff said the new manager had an open-door policy and was supportive. Relatives confirmed they had little contact from the manager. During, or shortly after, our assessment the manager left the organisation.

The provider lacked a clear vision and set of values to promote high quality care, person-centred care for people and to develop and value staff.

There was conflicting feedback from staff regarding the managers leadership and progress in terms of areas of improvement. Some staff stated the morale had increased since the manager started others felt there was no clear direction. The manager confirmed there were gaps with auditing systems due to the number of improvements needed. The manager told us they felt overwhelmed and received little support from the owner. During, or shortly after, our assessment the manager left the organisation.

The systems in place failed to identify the concerns we found during the assessment with regards to the environment, risk management, safe care and treatment, medicines, staff support, person centred care and good governance.

Feedback on the culture of the service was mixed, some staff stated the manager had improved morale whilst others stated there was no clear direction of responsibilities.

Staff told us they were not kept informed of changes to the service. A staff member informed us of the changes required to auditing systems, however felt that the manager had not listened to their feedback.

We received mixed feedback from staff regarding workforce equality and inclusion. Some staff reported they felt their feedback was not listened to and acted upon.

There was no evidence staff had received training in equality and diversity. There was no evidence to support staff were included in conversations to promote equity within the service and a fair and diverse culture.

Staff informed us they had raised areas that required improvements. The manager failed to acknowledge and respond to this feedback from other staff.

The governance systems and processes were unclear and ineffective, and the provider and manager lacked accountability and understanding of their role and responsibilities for ensuring the quality and safety of the service. Audits and checks were not used to identify risk and bring about improvements. The required records were not maintained, accurate or up to date including care records, safeguarding and accident and incident records. Policies and procedures were not followed to ensure the delivery of safe and effective care and safe working practices.

There was limited feedback from people about partnerships and communities. However, our observations and review of records showed limited opportunities for people to access the community. Staff told us, “We used to have an activities co-ordinator, but they left and people don't go out.”

Leaders did not demonstrate their duty regarding partnership working to ensure good outcomes for people and there was a lack of joined up approach to ensure individual people’s care was person-centred.

Visits from professionals and the local authority quality team had taken place and records were observed. It was unclear the progress of these actions as the manager did not evidence how they had addressed concerns identified.

We found the systems in place to share good practice and learning were not fully effective. This was evidenced by a number of concerns found at the last assessment that were still in progress or had not yet been addressed. Further action was required to ensure effective systems were in place to drive learning and improvement at the home.

The manager lacked knowledge and understanding of their role and responsibilities for ensuring learning and improvement across the service. They were unable to evidence any systems and processes implemented to demonstrate effective learning and improvement.

We found no evidence of improvements or lessons learnt since the last inspection. In addition, we found further concerns placing people at significant risk of unsafe care which had not been identified by the provider or manager. This led to people experiencing poor outcomes. There was a lack of recognition and accountability from the provider and manager of the seriousness of the concerns we identified during this assessment, and they were confident people received safe and high-quality care.