West Hill Care Home

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to good governance.

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 provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Prior to this inspection, the service had been rated requires improvement. During this inspection, we found a continuation of the previous breaches of the regulations as well as additional concerns. There was no effective strategy to ensure lessons and learning identified following the previous inspection had been embedded, and people continued to receive support that was not consistently safe or of a good standard.

The culture at the service needed to be improved. The systems and process in place had not led to a culture of safety within the staff team. For example, there were multiple incidents where staff had not reported or raised concerns in a timely manner. We also observed there was not always a culture of promoting dignity at the service.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation.

We were not assured leaders had the skills, knowledge, experience and credibility to lead effectively. Leadership had not led to improvement within the service and there was a lack of leadership from the provider, who was also the nominated individual.

Following the inspection the registered manager de-registered from the service. Although we have raised concerns regarding this service previously, the nominated individual had not implemented a robust system to maintain their own oversight of the quality of the service and drive forward improvement. The nominated individual was not present at the service and did not engage with the inspection.

There was no evidence the nominated individual was involved in the management of the service or had sufficient oversight of how the service was managed. They hold legal responsibility and accountability for any concerns at the service and must be in a position which carries responsibility for supervising the running of the service. There was no evidence the nominated individual was meeting this responsibility.

Staff did not always feel they could speak up and that their voice would be heard.

The provider had a Freedom to Speak Up policy in place and staff knew how to raise concerns with the provider or outside organisations if they needed to. Staff confirmed they were invited to meetings and encouraged to contribute. However, they did not always feel listened to. Staff provided mixed feedback about the management of the service.

Staff gave mixed feedback about the culture of listening the service. Some staff reported a positive culture at the service; however other staff gave negative feedback. Comments included, “We do have staff team meetings, and we can make suggestions” And, “Some suggestions are heard, others are not, like when we ask for more staffing. They don’t listen to us.”

The provider did not always value the diversity of their workforce.

Staff felt the registered manager recognised diversity within the team. One staff member told us, “If I needed time off work or a change in shift, I am sure the managers would support me. The deputy manager is brilliant and will always help if she can.” Another staff member said, “One of our team is Muslim and they are supported to pray whilst at work.”

The registered manager told us, “We don’t discriminate; we have different cultures within the staff team and service users from different cultural backgrounds.”

However, following the inspection we were informed of concerns regarding the treatment of some overseas staff. We are looking into these concerns.

The provider had clear responsibilities, roles, systems of accountability. However, they had not led to a system of good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider has continued to fail to ensure there was effective oversight to assess, monitor and improve the quality and safety of the service. Whilst there was a system of oversight meetings and audits in place these systems and processes had failed to identify and mitigate risks. This had put people at continued risk of harm.

Audits of medicines had not identified and addressed the concerns we identified during the inspection. Audits were not effective and needed more development to be adapted to the environment in which they were used. The medicines audit did not reflect the complexities of medicine administration in a nursing setting, or identify some concerns, such as those regarding medicines which were being crushed and administered covertly.

There were regular reviews of care plans. However, these had not led to care plans and risk assessments being up to date and free from error. There was a lack of detail in care plans, for example, a lack of guidance regarding how to support people who used a hoist.

Care plans included inconsistencies and contradictions. For example, one person’s care plan detailed welfare checks should be every 15 minutes, but another section said every 30 minutes. The registered manager confirmed the person only required hourly checks. One person’s daily records stated they had a “minced and moist” diet as per their Speech and Language Therapy Team (SALT) assessment. However, their care plan stated they required a Level 7 diet. Their nutritional care plan had not been updated to reflect this, meaning that there was an increased choking risk if staff were not aware of their appropriate dietary needs. One person’s care plan stated that staff were to adjust their insulin dose but elsewhere stated they did not require insulin. When we discussed this with the registered manager, it was confirmed that this person was not on insulin.

There were gaps in daytime care provision such as regular continence support for some people. We reviewed these gaps over a 6-week period for one person and saw did not improve despite the systems in place to address this.

The provider did not sufficiently understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Feedback from health care professionals was mixed. One health partner told us, “While referrals are timely, they sometimes refer inappropriately: for example, they might calculate a [score] incorrectly (higher than it should be) or not register that a patient’s status has improved before we see them.” Another health partner told us, “Sometimes records are incomplete; for instance [record charts] are not always filled in precisely. I sometimes wonder about the accuracy of weights given.”

However, another health care professional told us, “There are sometimes barriers preventing access to my service caused by language, and more commonly through residents declining to be seen. The staff are incredibly supportive in helping me explain why I am there.”

We identified delays in sharing concerns regarding incident which meant incidents were not always shared with partners in a timely way. Staff were still not recognising safeguarding concerns. One partner also raised concerns about the management and culture at the service.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

There was not an effective culture of learning which had led to improvement. There was a lack of learning or ability to sustain improvements at the service. The provider had failed to establish effective oversight of the quality of the service. Continued concerns were found in areas we had reported on before and told the provider to improve. The provider continued to fail to address concerns in regard to reporting and escalation of safeguarding incidents and the safe management of people’s health risks. Any action taken previously to make improvements was not effective or embedded. Learning and improvement were not valued to ensure staff were well trained and competent in their role.