Westfield Residential 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 good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider had a shared vision, strategy and culture that promoted improvement and person-centred care. Leaders communicated a clear focus on improving the service following changes in ownership and management arrangements. Staff consistently spoke positively about working at the home and felt supported by leaders. Staff told us leadership had responded positively to ideas and created an environment where people worked together to achieve improvements. One staff member said, "My ideas have been responded to positively." Staff told inspectors leaders were approachable and available for support, including out-of-hours on-call arrangements. One staff member said, “Staff here work as a team.” Leaders were actively driving improvement, including introducing electronic care records, strengthening policies, developing governance systems and supporting staff to develop confidence and skills.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The provider had capable and compassionate leaders who were visible, approachable and involved in the day-to-day running of the service. Staff consistently described managers who were actively involved in the day-to-day running of the home. One staff member told us,"[The provider] is very welcoming and supportive, open to ideas. [The registered manager] is brilliant." Another explained, “Yes, we can always talk to the [registered] manager and [provider]. I see them every day.” Leaders had introduced new systems, audits, training initiatives and governance processes following changes within the service and demonstrated a commitment to driving improvement. A healthcare professional spoke positively about leadership and organisation within the service.

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

The provider created an open culture where staff were encouraged to raise concerns, share feedback and contribute to improvements. Staff described having regular meetings, supervision sessions and opportunities to discuss concerns with managers. Confidential support arrangements and whistleblowing processes were available, including a confidential staff helpline. Leaders discussed duty of candour responsibilities with staff and reinforced learning through meetings, guidance and checklists. One staff member told us, “If ever anyone is struggling you can always ask what to do or if you're not sure and need a second opinion, the team and the office will always help.”

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.

The provider promoted an inclusive culture where staff felt respected, valued and treated fairly. Staff described positive teamwork and no concerns relating to discrimination or unfair treatment were identified during the assessment. One member of staff told us, "Staff here work as a team. I feel comfortable asking staff to do things." No specific concerns relating to equality, diversity or inclusion were identified during the assessment, and leaders provided wellbeing support and access to confidential support services. The provider also demonstrated a commitment to developing both new and existing staff through training and competency processes. One staff member told us, “They [the registered manager] make me feel comfortable, they don’t make me feel silly.”

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 provider did not always have effective governance, management and oversight systems in place. Leaders had recognised areas requiring improvement and had introduced new systems, including electronic care records, audit processes, action plans and monitoring tools. However, governance processes were not yet fully embedded and did not consistently identify or address concerns found during the assessment. Some audits reviewed were incomplete, unsigned or lacked evidence of action tracking and completion. Some care records and risk management documentation associated with the transition to the electronic care planning system were found to be incomplete or inconsistent. Leaders were aware of these concerns and took action following the inspection. The provider implemented additional governance measures including resident record reconciliation, daily reviews of outstanding tasks, focused audits, clinical review tools, escalation forms and enhanced governance monitoring arrangements. While these actions demonstrated a commitment to improvement, further time was required to ensure systems were fully embedded and consistently effective in identifying, monitoring and responding to risk.

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 provider worked collaboratively with healthcare professionals, relatives and community organisations to support people’s care and wellbeing. Positive working relationships were evident with GPs, pharmacists, district nurses, paramedics and other professionals, who described staff as responsive and organised. The service also promoted community involvement through church services, visiting professionals, social events and activities, including visits from a travelling museum, hairdressers and community groups.

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.

The provider was learning from incidents and had begun implementing improvements, but systems were not yet fully effective in driving consistent improvement. Leaders had responded to a recent safeguarding incident by developing emergency guidance, checklists and additional staff guidance, and had introduced an electronic care planning system alongside new audit and quality assurance processes. Evidence showed accident, incident and safeguarding monitoring systems were in place and monthly analysis was undertaken. However, some audits identified issues without demonstrating effective action planning, monitoring or completion. While leaders demonstrated a willingness to improve and had implemented a significant programme of change, further work was needed to ensure improvements were embedded and consistently effective.