Westholme Care Home Limited

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 good. At this assessment the rating has remained 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 71 (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 clear vision for the service which was shared with staff at the beginning of their recruitment journey. The managers made sure staff had the same values of the service. Staff said they enjoyed their jobs and felt listened to; there were long standing members of the team at all different staff levels.

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.

There had been a recent turnover of registered managers, who did not always possess the culture and values of the organisation, however this had been resolved. The current registered manager also led 3 other care homes so was supported by an area manager at Westholme Care Home Limited. The managers told us they led by example and fostered an ‘open door policy’ to support staff to feel included and supported. Staff said they felt supported in their role and in their personal lives.

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

There was a whistleblowing policy and staff said they would feel confident to raise any issues, and they would be listened to and acted upon. Where lessons had been learned following investigations or concerns, these had been shared with staff in a timely manner to make sure improvements were made and maintained.

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.

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.

There was a schedule of audits to monitor outcomes and performance. However, audits did not identify or address issues we found regarding medicines management or the environment. Some information about risks to people’s health was missing or contained discrepancies.

However, the provider engaged well with external agencies that conducted audits such as the local authority team and were responsive in addressing issues following feedback.

The registered manager understood their responsibilities regarding the duty of candour and submitted notifications to the relevant agencies which is their legal responsibility to do so.

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.

There were links with the community, and the local faith leader visited the home regularly. Staff supported people to go to local shops and cafes. A local hairdresser visited people at the home on a regular basis.

The provider 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. They actively contributed to safe, effective practice and research.

Leaders could access additional training and participated in forums and groups to keep up to date with current guidance and best practice. The registered manager analysed incidents to learn lessons and make improvements to the service.