Westacre Nursing 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 regulations in relation to good governance.

This service scored 57 (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 a clear vision for the service, based on person-centred care and people’s rights. Processes and practice did not consistently demonstrate these goals were achieved for people.

Staff completed training in equality, diversity and human rights. The shortfalls we found in practice in relation to capacity, mental capacity assessments, consent and DoLS meant staff had not always upheld people’s human rights in relation to all aspects of their care.

One of the provider’s aims was to provide person centred care. However, processes did not always fully support staff by ensuring people’s care plans were fully person centred and reflective of their preferences about their care and their individuality, to guide and inform staff.

However, staff learnt about the provider’s values during their induction, and these were embedded on the staff shift handover which ensured their visibility to staff.

The registered manager had processes in place to have oversight of and monitor the culture of the service. These included their daily report, weekly walk of the floor, spot checks at night and staff meetings. Staff spoken with told us they were happy in their work.

The provider had inclusive leaders who understood the context in which they delivered care, treatment and support. Leaders’ knowledge of all areas and responsibilities was not fully robust in order to provide effective leadership in relation to all aspects of the service.

The registered manager was not aware of their duty to inform CQC of the outcome of DoLS applications. At the site visit we identified 12 people had an authorised DoLS but DoLS notifications had not been made. Although the registered manager acted immediately once we informed them of this legal requirement and submitted them. They had a responsibility to ensure they were fully aware of all CQC notification requirements and ensuring they were submitted.

As detailed throughout the report, whilst the registered manager was an experienced mental health nurse and the deputy manager an experienced general nurse, and they had a breadth of experience and knowledge which they used in their leadership of staff, there were specific areas such as capacity, mental capacity assessments, consent and DoLS notifications where the registered manager’s leadership was not fully effective.

However, staff reported the management team were visible and they felt well supported by them. Staff were enabled to develop their skills and knowledge through the completion of further professional qualifications or adopting champion roles within the service.

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

Staff had access to the providers guidance and information about how to whistle blow or raise any concerns. Staff told us they felt able to raise issues and they were confident any concerns raised would be acted upon. The recent staff survey confirmed this, with 93.6 percent of staff agreeing or strongly agreeing concerns would be investigated and lessons learnt.

Staff were able to raise concerns directly with management, through their supervisions, staff meetings or through the provider’s whistleblowing process.

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.

Staff told us they felt treated fairly by the provider, who had processes in place to ensure fairness and equity in workforce practices across the staff group. These included relevant training and policies.

The provider did not have robust governance processes.

The registered manager audited and analysed many aspects of the service. However, not all audits and checks were fully robust, as they did not always identify and address foreseeable potential risks to people, or include all relevant areas.

Systems and processes had not identified the concerns we found in relation to consent to care, governance or staffing. This meant people were exposed to a risk of harm or their rights were impacted. As well as the other quality statements where a 2 was scored, which meant improvements were required.

Audits had not identified people’s care plans were not always person centred, as detailed within this report. They had not identified the, 'This is me' document did not include all relevant areas related to the provision of personalised care. Therefore, care plans lacked sufficient information about peoples' preferences about their care as well as their clinical needs.

Staff completed a daily audit of the kitchenette fridges which included a food expiry date and label check. However, food items stored in the cupboards were not checked. The IPC audit did not identify the issues we found with a bed bumper and a crash mattress. The audits completed did not include all relevant areas.

The registered manager had not identified the chef was not informed about peoples’ weights, particularly those at risk of weight loss. Records showed in May 2026, 9 people were assessed as at high risk of weight loss. The importance of the chef being informed of peoples’ weights is reflected in national guidance and the provider’s lunchtime experience audit guidance. Whilst people’s weights were monitored, the chef was not informed to ensure they knew whom was at risk. The registered manager acted once we brought this to their attention.

People's daily records did not evidence where they required the use of incontinence products, these were changed as frequently as required within their care plan, some people had large gaps in their records between changes. The registered manager told us these were gaps in records rather than care not having been provided. However, people should all have complete records of their care delivery, to demonstrate they have received their care as described.

However, audits were completed in relation to clinical care, where any issues were found, these were followed up. Staff were provided with feedback on the outcome of audits.

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.

The registered manager worked with a wide range of professionals and agencies to plan and deliver people's care. They ensured people were referred as required and external guidance received was then acted upon.

Staff also worked with the local community. For example, staff had worked with the local university to provide information for people in braille and with students to run a flower arranging activity for people. Staff had also accessed end of life training through the local hospice.

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.

The provider had some mechanisms for learning and improvement, but there were still areas requiring improvement.

The registered manager ensured there was a focus on identifying areas for improvement through a range of internal audits and analysis of the service. The outcomes and learning were then shared with staff. Gaps within governance processes as described elsewhere within this report meant not all relevant risks and learning were being identified, to enable them to be addressed and shared with staff.