Welham House

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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 identified a breach of regulation in relation to the governance and managerial oversight of the service. The provider failed to have clear and effective governance, management and accountability arrangements. The provider failed to have processes to ensure that learning happened when things went wrong. Staff and leaders did not have a good understanding of what was required to ensure people’s care and safety improved. Staff and leaders did not always demonstrate a positive, compassionate, listening culture that promotes trust and understanding between them. We were not assured that leaders had the experience, capacity, capability and integrity to ensure that the organisational vision was delivered, and risks were well managed. The provider failed to have a system for staff at all levels to raise their concerns without fear of reprisal.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The manager was open and honest about the homes current position and said, “It’s [the service] not where I want it to be yet,” they said that they had only been at the service for the last 2 weeks. Following the assessment the provider shared an action plan with us where they expressed that there had been failings from the former manager.

Staff and leaders did not demonstrate a positive, compassionate, listening culture that promoted trust and understanding between them, people using the service and was not focused on learning and improvement. The provider had not ensured all staff were fully trained.

The service had not had a registered manager in since February 2022 and 2 managers prior to this assessment. The current manager had only been at the service for the last 2 weeks. They were a registered manager for another service under the same provider. They had been asked to manage Welham House and 2 other services. There were no formal plans in place as to how they would spend their time between the 3 services. After a discussion with inspectors about the service needing support, the manager said that they would spend more time at Welham House than the other services at it would need more of their time. The provider had failed to ensure there was a capable and compassionate manager in place at the service. We received mixed feedback from staff about both the manager at the time of the assessment and the former manager who was still working at the service.

Systems and processes in place had not identified the issues we identified during our assessment in relation to the culture which had impacted on people’s care. The provider’s quality audit had not identified the shortfalls we found during our assessment.

Prior and during the assessment process we received whistleblowing’s from staff who did not feel the provider would listen or act if they were to go to them with their concerns.

As part of the assessment process, we reviewed the providers policies and procedures including the whistle blowing policy. This policy was not clear in how staff would be supported to raise concerns and ensure that those that did could do so without fear of victimisation, subsequent discrimination, disadvantage or dismissal. Although the policy stated it cover how concerns would be dealt with this was not included in the policy.

We had received whistleblowers from staff of sexual harassment towards female staff. We were not assured these allegations were properly investigated. Staff told us that they were allowed to work flexibility. Senior cares had requested to work 2 long days together to include a sleep in shift in the middle of this shift. Staff were also allowed to leave the service if they had personal appointments such as hospital appointments. However, we were not assured that this was not at the risk of lack of support for people living at the service.

The provider had policies in place to ensure staff were treated fairly with an inclusive approach. For example, the provider made reasonable adjustments to enable staff to carry out their role. The provider had a policy on equality and diversity. However, we were not assured these policies were followed by either staff or leaders at the service or provider level.

Staff told us there had been a lot of changes of management and that they had not always felt that the managers were effective in their roles. We were told that the provider did not support managers at the service.

There were ineffective processes to ensure that lessons were learnt, and improvements made. There was no oversight of accidents and incidents. There was not a clear system of how and where to report and document incidents. Incidents had not always been reviewed by the manager or provider to ensure appropriate action had been taken. When incidents occurred, care plans had not always been reviewed and updated to inform staff of any new concerns, potential triggers, or de-escalation techniques. Review of incidents to look for patterns and trends were not effective or acted upon.

People at the service were supported to access the community. However, this was often in a group with other people from the service. A family told us that their loved one had missed going to the day service that used to be run by the provider.

Staff and leaders did not always assess peoples needs before they accessed the community putting people and the community at risk.

An agency that had been brought in by the local authority to support staff told us that they did not feel staff assessed people prior to going into the community.

Systems and processes in place were not always effective in identifying what support people needed when they accessed the community. Senior leaders had prompted managers to make referrals to external agencies such as for support with people’s mental health. However, we were not assured that these referrals were always made in a timely manner.

Leaders did not demonstrate a good understanding of identifying and actioning continuous improvement in the quality of the service. Staff told us that they did not receive debrief following incidents.

When incidents occurred at the home, these were not always thoroughly investigated. There were not always records of any debriefs with people or staff in respect of these incidents and they had not been used in line with the provider’s policy to develop peoples care plans.