Westerley Residential Care Home for the Elderly - Westcliff-on-Sea

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• 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. Systems were not robust enough to evidence effective oversight of recruitment checks.

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 service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion. The service focussed on staff engagement with people and their communities gaining an understanding of their needs. The registered manager told us they had worked hard to change the structure and processes within the service to drive improvements. The registered manager told us, “Together we have tried to change our processes to ensure they are more robust, and we now have effective and efficient systems in place.” The management had clear values and had developed a listening culture where staff felt they were available for them to talk to. The nominated individual acknowledged further improvements were required within the service and agreed to introduce more formal, structured meetings with the registered manager to have regular discussions.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion. The service focused on engagement with people and their communities gaining an understanding of their needs. The registered manager told us, “We have worked through the action plan and everything that was picked up from the last inspection.” The management had clear values and had developed a listening culture where staff felt they were available for them to talk to.

All relatives we spoke with referred to the deputy manager as the manager. This meant the deputy manager was seen as the main point of leadership for relatives, which indicated limited visibility and oversight from the registered manager.

A relative told us, “The manager is [deputy manager]. They have an open door and is usually around when I need to speak to them. They are very responsive, excellent. I was in a similar profession, and they are always very receptive to any comments and suggestions, and they do change things for the positive. It’s great.”

However, some relatives felt they were not listened to. A relative told us, “I don’t feel listened to and our views are not respected. I tend not to speak to one of the managers as they can be abrupt.” The registered manager was aware of the concerns and was working to resolve them.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager had a policy and processes for staff to follow on ‘whistle blowing.’ 

The registered manager also held regular discussions with people to share their thoughts about how the service was ran and to discuss the support they received and if any improvements could be made. A member of staff told us, “We have regular meetings and supervisions with the manager which is a good opportunity for us to discuss anything with them.”

Improvements have been made since the last inspection. All staff were now receiving regular supervision. There was now effective arrangements in place to monitor staffs’ performance and professional practice.

We reviewed staff meeting minutes and saw they included information about the service as well as reminders about training, staff rota’s, safeguarding, incidents and PPE. There was detailed action plans completed to evidence how issues raised were to be addressed, dates to be achieved and if actions had been resolved or remained outstanding. However, the managers meeting minutes lacked detail and there was no action plan completed to evidence how issues raised were to be addressed.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Improvements had been made since our last assessment. However, the provider remained in breach of legal requirements. The quality assurance and governance arrangements in place to ensure recruitment checks were completed were not always effective in identifying shortfalls. The staff file audit completed by the deputy manager identified the same shortfalls we found. However, the audit did not include any action plans to show how these issues would be addressed, the timescales for completion, or whether actions had been resolved or remained outstanding. There was a lack of monitoring by the registered manager, who did not demonstrate appropriate management oversight of staff file audits and recruitment practices.

The provider had not fully met the actions from the previous action plan, and several required improvements had not been sustained. Governance processes also failed to identify environmental concerns, such as the issues with newly installed fire doors, which were highlighted during this assessment rather than through the provider’s own checks. This showed that monitoring systems remained ineffective in identifying and addressing ongoing shortfalls. Monthly audits were being completed by the deputy manager. The registered manager needed to maintain oversight by reviewing the audits and ensuring all actions identified were completed.

The service 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 management had developed good links and worked closely with health professionals. This included GPs, district nurses, occupational therapists and social workers. Managers had worked closely and transparently with the local authority quality improvement team to work through identified actions and make improvements at the service.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. The management was actively supporting staff with learning and innovative ways of working at the service. The CEO agreed they needed to work more closely with the registered manager to monitor the service and support continuous improvements being made. The registered manager continued working through an action plan and service improvement plan to address identify shortfalls and drive sustained improvements in the home.