Wombwell Hall

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

The findings at this assessment show the service is Requires Improvement in relation to the Well-led domain. We found one breach of the legal regulations in relation to good governance. The service’s governance systems and audits were not effective in identifying or addressing areas for improvement. Continuous improvement was not always driven by the governance, checks and audits that were in place. Staff were positive about the culture of Wombwell Hall and felt able to raise concerns and were supported in their role by their line manager. Staff felt they worked well as a team and worked alongside external healthcare professionals when required. Although the service engaged in partnership working, we received mixed feedback from professionals and our observation was the service was not always effective at promoting positive outcomes for people.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were positive about working at Wombwell Hall. They were clear on the company's vision and values and felt there was a positive culture within the home. One staff member said, “The management of the company is good. They listen and share their vision and direction.”

The provider had documented the service vision and values, these aimed to promote a positive culture within the service. This included to strive to enhance people’s quality of life by providing a safe, comfortable homely environment and care that met their needs. There were systems in place to review the quality of care for people and to support the staff to come together and feedback on the service. For example, the recent staff survey from May 2024 contained mostly positive responses about everyone working as a team.

Leaders and senior staff within the service felt supported to carry out their roles and told us they, “Get everything they need, they just need to ask, no problems.” Staff told us the registered manager put them at ease and the teams worked well together.

However, during our assessment we found that leaders and senior staff had not always understood their roles and carried them out effectively to keep people safe. For example, where people did not have risk assessments in place, when we spoke to the staff, they said they had not realised they needed to complete them. Assessment tools had been used to identify the level of risk however, the risk assessments had not been completed to inform staff how to mitigate these risks.

Staff knew the process to speak up about any concerns they had. One staff member said, “There is a number given to us to whistle blow externally.” Speaking up was seen as a good thing and a way of addressing areas for development. A staff member told us, “Speaking up is good to help improvement.”

There were systems and processes in place to support staff to speak up and raise concerns.

Staff we spoke to were happy working at Wombwell Hall. One staff member said, “No concerns with equality, diversity and inclusions.”

There was a diverse staff team at Wombwell Hall and there were systems in place to ensure Wombwell Hall was inclusive for staff. Staff had completed equality, diversity and inclusion training to raise awareness and foster a positive work environment.

Staff told us they felt the service was well managed. Managers told us they had had a recent internal inspection that they felt they had done well in.

There were systems and processes in place to support the management of the service. However, Staff could not always operate systems effectively such as the electronic medication monitoring system. A timeframe for audits was in place however this was not always consistently followed for example medicines audits were not consistently completed to ensure the safe management of medicines. The provider contracted a quality manager who completed additional audits with the aim of improving the service for the provider. However, audits had not always effectively identified issues for improvement. Some of the themes of areas for improvement we found at this assessment such as issues with people’s risk assessments and care plans had been identified in previous audits however, these had not always been effectively acted on to ensure overall compliance in this area. The registered manager told us they would use new audits to make them more robust.

The registered manager had formed links with the local community for example, visits from the local school and spiritual leaders visited the home. One person told us they enjoyed the visit from school children however most people we spoke with did not provide feedback directly about partnership working. Some people commented on access issues which limited their engagement in the home or felt some activities did not appeal to them. Our observation of people’s experience was mixed about the impact these partnerships had for some people.

Staff told us they worked in partnership with other healthcare professionals to assess and met the needs of people they supported.

Feedback from health and social care partners about working with Wombwell Hall was mixed. Some healthcare professionals said partnership working was more effective at some times than others, they had fed this back to the service and felt this was improving. One health care professional shared positive feedback that Wombwell Hall supported with emergency placements for people positively which impacted on them not having to have unnecessary hospital admissions. Though we also received feedback that poor communication had resulted in the opposite at times previously.

There were systems and processes in place to prompt partnership working with health and social care professionals such as when referrals were required to other health or social care professionals. However, there had been occasions where this had not been completed effectively and had impacted on people as reported in other parts of this assessment report. Care records showed people had input from other healthcare professionals when their health deteriorated, and specialist input was required. The provider had hosted various charity events, inviting the community into Wombwell Hall in support of Elleanor Hospice.

Leaders and staff demonstrated an openness to reflection and learning. Staff gave examples of some learning that had been implemented following negative feedback that had been received to prevent future similar incidents. The registered manager was receptive to feedback from the assessment, they said, ‘It’s always good to learn and share knowledge to help us grow.’

Processes in place allowed for learning and improvements to be extracted from the overall governance of the home. However, learning and improvements were not always consistently actioned or imbedded from either quality assurance processes or governance systems and processes.