Westwood 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 remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance. This was because systems to support quality and continuous learning were not operating effectively.

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.

The provider had not established a consistent approach to engaging people and ensuring their views, goals and aspirations were used to shape care and support..

Although significant effort had been made to maintain a positive culture, the provider had not established a clear or consistent approach to driving improvement, and there was limited evidence of how their vision was put into practice.

Staff told us they would report poor practice and expressed confidence that management would act on concerns. However, formal learning opportunities from accidents and incidents was lacking. Following our feedback, the provider and home manager began developing a plan to address the issues identified, including sharing key improvement priorities with staff.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

The home manager spent considerable time working alongside staff and supporting care delivery. They were visible within the home and regularly engaged with people and staff, contributing to an approachable and positive atmosphere. However, this reduced the time available to carry out their managerial responsibilities and ensure full regulatory compliance.

Although supported by a deputy manager, these roles were not used to their full potential. For example, responsibility for checking documents could be shared to support with identifying issues, such as the missing PRN protocols.

Staff feedback was consistently positive, with comments such as, “[Home manager] and [the deputy manager] are superb. I absolutely feel supported and would go to either of them if I had any worries.”

In response to our feedback, the provider had begun taking action, showing a willingness to address concerns. However, further time was required for these improvements to be fully implemented and embedded.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff spoke positively about the home manager and their approachability. There was an on-call system where staff could contact a member of management out of hours should they have concerns. There was a whistleblowing policy in place for staff to use if they did not feel able to speak up. However, staff told us they felt listened to and were able to openly discuss any issues they had, with confidence that they would be dealt with without judgment. We observed staff communicating with each other and with the home manager throughout the days of inspection.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was a long-standing staff team who worked well together and respected each other’s differences. Management made reasonable adjustments where required, including adapting duties and working patterns to help staff remain in work. All staff members we spoke with stated they felt they were treated equitably and supported fairly. Staff had undertaken training in equality and diversity.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The home manager was present in the service and knew people and staff well, however, governance and oversight from leaders was not robust to ensure consistent good practice. Audits and checks were lacking in some areas and failed to consistently identify key risks, including those found by inspectors during their visits. These included environmental hazards and lack of meaningful activities. These shortcomings placed people at risk.

Quality assurance systems were not strong enough to support the identification of ongoing concerns. For example, environmental audits had either missed concerns raised, or matters had been reported but no action taken to address these. This meant opportunities to improve care were missed.

The provider did not consistently have oversight and there was no formal support system in place for the home manager. While the home manager responded to issues once raised, these were not identified through internal systems, indicating a reactive rather than proactive approach to governance.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff had positive working relationships with visiting services, which helped ensure people received input from the right agencies at the right time. One professional told us, “Communication with the home is great. [Home manager] is always present when we need to discuss people’s needs. The home take on board any advice given. [Person] has settled and feels safe which is the main thing.”

The home manager and provider also engaged well in local forums to discuss wider experiences across the local geographical patch. They had visited other care homes to gain knowledge and learning for improvements to be made.

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

Systems to ensure learning from incidents were not embedded in practice. Some learning was shared informally, and while staff discussed issues during handovers or when concerns arose, these discussions were not always documented. Oversight of accidents and incidents was not robust.

Innovation was limited, though leaders were receptive to feedback and showed a wiliness to learn and improve from the concerns raised. The home manager planned to involve external professionals to support improvements and strengthen learning. The leaders recognised the value of connecting with other care home managers to share learning and collaborate, and were committed to gaining more knowledge from others.