• Care Home
  • Care home

Widecombe Nursing Home

Overall: Requires improvement read more about inspection ratings

36 Grasmere Road, Luton, Bedfordshire, LU3 2DT (01582) 505575

Provided and run by:
Niram Investments Limited

Important:

We served warning notices on Widecombe Nursing Home on 16 July 2024 for failing to meet the regulations related to safe care and treatment, person centred care and governance.

Report from 27 June 2024 assessment

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Well-led

Requires improvement

Updated 18 July 2024

We identified 1 breach of the legal regulations in relation to governance. There was no clear support structure in place for the management team. Quality assurance and governance systems were not effective in monitoring the quality and safety of the service.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Shared direction and culture

Score: 2

We received mixed feedback about the culture in the service. Some staff were positive and complimentary about recent changes in the service and leadership team, highlighting a positive change since the registered manager had joined. However others told us they did not always feel listened to, either by the management team or directors.

The provider did not have a clear vision or strategy to drive improvement in the service.

Capable, compassionate and inclusive leaders

Score: 2

We received mixed feedback about the leadership team. Staff were complimentary about the registered manager however felt the wider leadership team did not always seek feedback and listen to their views. One staff member said, “The atmosphere changed a lot and made it so much more pleasant. But I do feel like we need to get listened to more.”

There was no clear support structure in place for the management team in the service. We found examples where concerns had been escalated to the provider with no clear response, action plans or timescales for completion set out by the provider. It was unclear what support was in place to drive quality and improvement in the service.

Freedom to speak up

Score: 2

Workforce equality, diversity and inclusion

Score: 2

Governance, management and sustainability

Score: 1

The registered manager told us they had introduce a number of quality checks since joining the service, however acknowledged the shortfalls in the quality assurance systems.

Quality assurance and governance systems were not effective or robust. The provider did not have processes in place to monitor the quality and safety of the service. Risks to people using the service were not always identified. We found multiple examples where records were missing or incomplete. The provider had a quality assurance policy in place, however this failed to set out clear guidance for staff on how to implement, monitor and develop any quality assurance systems. The provider failed to maintain oversight to ensure records were accurate, complete and contemporaneous. Although the provider took action in response to some of our concerns, this was as a result of our findings and feedback rather than the providers own processes.

Partnerships and communities

Score: 2

Learning, improvement and innovation

Score: 2