Wollaton Park 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 assessed 7 quality statements in the well-led key question and found areas of good practice. The scores for these areas have been combined with scores based on the rating from the last inspection, which was inadequate. The assessment of these areas indicated areas of good practice and significant improvement since the last inspection, our rating for the key question has improved to good. There were clear and effective governance, management and accountability arrangements. Staff understood their role and responsibilities. Management accounted for the actions, behaviours and performance of staff. The systems to manage current and future performance and risks to the quality of the service took a proportionate approach to managing risk. Data or notifications were consistently submitted to external organisations as required. There were robust arrangements for the availability, integrity and confidentiality of data, records and data management systems. Information was used effectively to monitor and improve the quality of care. Leaders implemented relevant recognised standards, best practices or equivalents to improve equity in experience and outcomes for people using services and tackle known inequalities.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager, deputy and staff now felt involved in the shaping of the service and told us they felt empowered. There was a robust service improvement plan in place to track developments and ensure the required measures were taken to maintain the service to a high quality, safe standard. The registered manager, deputy and staff team all told us they had made suggestions for improvement measures which had been listened to by the providers. One member of staff told us, “I can report any issues and feel they would generally be responded to quickly. I think we’re doing well and have definitely improved since the last inspection.”

The provider had ensured effective systems were in place to promote a positive culture of transparency, learning and improvement. The provider had systems and processes in place to ensure people and their representatives were engaged and involved in the arrangements of their care and treatment and to the improvements of the service. The provider had processes in place to ensure that staff supervisions, team meetings and residents’ meetings were meaningful and effective. The staff team were positive and felt they had a role in the shaping of the service.

The nominated individual and providers had given their full commitment to investing in the service, acknowledging their previous poor performance and ensuring a robust approach to improvements. The whole staff team gave positive feedback about the registered manager and deputy, describing them as, ‘dedicated’, ‘caring’, and ‘supportive’.

The service was led by a dedicated leadership team, working hard to embed the required improvement measures identified at our previous inspection. This left people with positive outcomes and a safe, quality, lived experience. People, relatives and staff were now involved in shaping the service. The provider had a service improvement plan in place, with allocated tasks and monthly auditing being completed to assess progress. They had employed a full-time maintenance person to progress with the required works identified at our previous visit.

There was a whistleblowing and freedom to speak up policy for the service. Staff told us they knew how to raise concerns externally if they felt people were at risk of harm. We found that where staff and people had been exposed to risk, concerns had been raised appropriately, meaning people and staff were protected from the risk of harm.

The complaints process in the service was clear and effective. One person said, “I’ve not had to complain but if I was really worried, I’d be ok to see the manager.” We saw the provider had analysed and had oversight of themes and trends of any complaints or concerns. The provider could demonstrate how they would prevent similar issues from happening again, as they learned lessons from previous outcomes. A clear process for induction and supervision of staff was in place, and all staff had received regular supervision, including the registered manager and deputy.

The provider actively encouraged workforce engagement. One member of staff told us, “We have supervision every 3 months with the deputy. It is useful, they ask about our welfare, it is not just work related issues.”

The provider showed a good knowledge and understanding of workforce equality, diversity and inclusion within their recruitment process. All staff had completed training in equality and diversity and understood the importance of respecting differences and ensuring an inclusive workplace.

All the staff we spoke with told us how they had felt the service had improved since our last visit. One staff member told us they felt the service was ‘calmer’ and another staff member said, “We’ve had a change of furniture, when you come in you can smell a nice freshness and you can feel a good presence.”

The registered manager and deputy showed evidence of lessons learnt and improvements implemented as a result of incidents that had occurred. The provider and registered manager had ensured they reported notifiable incidents to the CQC as required by law. Feedback from staff provided assurance of robust and effective, governance and oversight systems at the service. The provider ensured the systems and processes in place were effective. There was accident, incident and falls analysis in place. This meant the provider had the systems in place to identify themes and trends to inform them how to improve support and safety for people. There were provider audits of care plans which meant the service had effective oversight, ensuring people were not placed at risk of having unmet needs.

People and their relatives gave positive feedback about the availability of the management team and the good relationship between the registered manager and the staff team. One relative told us, “I see the manager on my way in sometimes and find them approachable.” Another relative told us, “The deputy is lovely and I can have a laugh with [Name], which helps.”

The provider, registered manager and deputy told us they were confident in asking for support from external agencies, such as the local authority or health teams, where it was needed.

The local authority were positive in their feedback that the service was proactive in engaging with a range of professionals and agencies and relevant professionals were involved in care and support planning for people.

We saw evidence of positive partnership working throughout people’s care planning documents. There were clear systems in place to ensure professional input was sourced in a timely manner to improve outcomes for people. People who were at high risk of falls had referrals made on their behalf to support risk mitigation. External health teams’ information regarding diabetes and nutritional support management was included in people’s care plans. Contact with relatives was recorded on incident records, including information about the incident and any subsequent actions taken. It was clear the duty of candour was being followed by the service. One relative told us, “They’ve rung me a few times with any updates and will have a word when I come in.” Another relative said, “They will ring if there’s any news or if a hospital visit is needed.”

Staff were encouraged to participate in a range of training to support them to provide quality care for people living at Wollaton Park. One staff member told us, “There is enough training for me. I will always ask questions if I’m not sure. If I’m interested in any more training I will speak to my manager.”

The provider demonstrated a focus on continuous learning and improvement across the service. The provider ensured they had systems in place to deliver a quality experience, positive outcomes and good quality of life for people. The provider had improved the living environment for people, and ensured people’s care was safe and effective.