Whitehaven 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 good. At this assessment the rating has changed to 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 care.

The service was in breach of legal regulations in relation to governance at the service and notifications.

This service scored 43 (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 did not always demonstrate a clear shared vision, strategy and culture which was based on inclusion, and engagement. They did not demonstrate a culture of continuous improvement for the service.

The provider told us they completed quality improvement audits about the service; however, we were not provided any written evidence of these. This meant we were not assured there was effective oversight of quality improvement of the service

The provider was not able to demonstrate prior to the inspection there was a service improvement plan in place, although the provider produced 1 after the first day of the inspection, which was based on some of the issues we had identified. This meant the provider could not demonstrate there was a culture of learning and development at the service.

The provider did not have clear vision about how to promote a positive culture at the service. They were unable to provide written evidence to demonstrate any work completed to champion the values and aims of the service. They were unable to provide CQC with a statement of purpose, which is a legal requirement for services registered with CQC. A statement of purpose is a document providers submit to CQC to which includes details of key information about the service.

However, the provider told us the ethos of the home was it is a family home. This was reflected in the care provided.

The provider engaged with, and provided support to people, throughout the inspection. We saw people knew and trusted them. Staff told us it was a positive place to work.

After the first site visit, the provider submitted evidence of a mission statement which identified the values for the service. This was in response to our post inspection feedback and was not in place as required at the time of inspection. We could not be assured without the inspection this would have been created.

The provider, who was also the registered manager, did not demonstrate they had the required leadership and management skills and up to date knowledge to ensure the organisational vision could be delivered, regulatory requirements met, and risks were well managed.

Although the provider was supported by a head of care and senior staff, there was a lack of depth in the structure of the management team. For example, staff told us there had not been a deputy manager at the service for approximately 3 years. This meant there was a lack of support for the provider in ensuring all risks were mitigated and management tasks completed, to ensure people’s safety and welfare.

The provider was unable to provide CQC with a significant number of documents and evidence requested as part of this inspection, despite multiple requests both on site and post the site visits. For example, evidence of audits or spot checks on the culture of the service, or the quality of care provided were not supplied. Therefore, we were not assured the provider had effective systems or oversight in key areas of the quality or safety of the service.

We have been unable to corroborate with written evidence, some of the verbal assurances supplied by the provider on a number of occasions. For example, we were told staff had received the training and guidance required to manage the home in the provider’s absence. However, there was a lack of training records to demonstrate this.

We found shortfalls in the provider’s governance processes around staff recruitment. They were not able to provide evidence all staff recruitment records included the information required by Schedule 3 and the Fit and Proper Person Requirements. For example, there was no evidence all staff had a current DBS in place; Right to Work checks were not always completed fully; and there were unexplained gaps in staff's employment histories.

The provider told us it had been a challenging year, for example, managing staffing levels, staff sickness and the transition from the old care planning system onto a new system.

Professionals told us the provider actively engaged with them.

There were not always the systems in place to enable people to speak up and to ensure their voice would be heard.

The provider was unable to provide, upon request, policies around speaking up and whistleblowing. This meant staff did not have written information and guidance to support them to speak up or whistle blow if they had concerns. Staff told us they had limited opportunities to meet as a team to give feedback, raise concerns or share best practice. For example, staff told us staff meetings had not taken place for a period of time. This meant there was a risk staff may not raise concerns. However, staff spoken to told us they knew how to whistle blow.

After the inspection the provider submitted evidence of a policy related to whistleblowing. However, this was dated July 2025 and therefore not in place at the time of the inspection. We could not be assured without the inspection this would have been created.

The provider did not always improve equality and equity for people who worked for them, they did not always demonstrate they value diversity in their workforce.

The provider was unable to demonstrate written evidence of any work carried out in relation to equality, diversity and inclusion. For example, the provider did not provide any policies to demonstrate they worked in line with current best practice with regard to staffs’ rights and wellbeing.

Not allstaff had completed equality and diversity training to help them understand about protected characteristics, bullying and harassment.

The provider sent a survey to staff which coincided with the inspection. The provider reviewed the data and plans to take action as a result.

The provider told us they had supported some staff with reasonable adjustments to enable them to carry out their roles. They told us they had supported some staff to access alternative types of training, to meet their learning needs. There were opportunities for development and staff had been promoted.

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

The provider did not have effective systems to ensure the availability of records. The provider was unable to locate or forward to us, a significant number of documents requested as part of this inspection. For example, written evidence was not provided of trends analysis and actions for accidents, incidents, falls, or people’s weight management. These documents were requested on multiple occasions over a 2-week period. These were not forthcoming and therefore we could not be assured these were in place.

The provider’s records and systems were not always clear, such as rotas and training records. For example, the staffing rota did not always reflect which staff member was allocated to administer medicines, therefore there was potential for confusion for staff. This meant there was a potential risk of people not receiving their medicines safely. The staff training matrix did not include all staff, and training records were split across different formats. This led to a lack of effective oversight of staff training, for example, not all staff had completed their required training.

The provider did not manage the transition to the new care planning system effectively. Staff had not received sufficient training on the new system. The provider did not ensure people’s records, such as care plans and risk assessments, had been transferred fully to the new system, prior to its launch. The provider did not to demonstrate they understood the new system sufficiently well to enable them to transfer the existing documentation over in a timely manner, or to adequately instruct staff. Staff did not have full access to all relevant information about people and were not able to record people’s daily notes effectively.

Services registered with the Care Quality Commission (CQC) are required to notify us of significant events and other incidents which happen in the service, without delay. This enables us to check appropriate action is taken to ensure people were safe.The provider had failed to notify CQC of reportable events, including1 person's death and the outcomes of 4 people's DoLS authorisations. One notification for a person's fall was received during the inspection, however, it was not submitted in accordance with the guidance on our website. Two months after the first site visit the provider submitted 5 statutory notifications. These had not been submitted in a timely way after the incidents and had not been submitted during our inspection process.

The provider’s auditing and quality assurance processes were ineffective in identifying issues and promoting improvement. The provider told us they completed audits of the service every 2 months; however, we were not provided with written evidence of these. For example, the provider did not demonstrate they had audits in place to ensure all recommendations to keep people safe had been completed, such as actions identified by the fire brigade and the fire risk assessment.

The provider’s systems had failed to identify risks to people from the environment identified at this inspection, such asthe unsecured gate leading from the garden to the road.

The provider told us they informed staff about risks at the service and any improvements needed, by speaking to them, email and the handover. However, we have not been provided with any written evidence to demonstrate information had been shared. This meant staff may not have the information they need to support people and keep them safe. For example, staff spoken with did not know the correct mattress setting for 1 person’s air mattress.

The provider did not always provide written evidence they collaborated and worked in partnership with external agencies.

The provider did not provide written evidence of communication with staff through meetings; or processes and policies in place to ensure suitable referrals to external partners were made. However, partners told us the provider made appropriate referrals to healthcare professionals.

The provider informed us at the start of the inspection they knew there were shortfalls at the service. However, there was very limited evidence the provider had taken steps to address issues or sought support from external resources to improve the quality of care. However, following the inspection, the provider told us they had arranged support for staff training on the new care planning system.

Partners told us records were not always up to date. However, they were positive about the provider. For example, they told us the provider advocated on behalf of people and they participated in external meetings.

The provider did not always focus on continuous learning, innovation and improvement at the service. They did not always demonstrate how they encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

The provider told us they had quality assurance systems in place; however, there was a lack of evidence of these. They did not provide evidence to show how quality assurance systems operated to ensure continuous improvement in the service.

The provider did not demonstrate written evidence to show how they promoted a culture of learning, best practice, improvement and innovation. They told us 1 staff member suggested moving furniture to create more space for people, however, mechanisms were not in place to measure the impact of any changes made.

The provider did not demonstrate written evidence of policies and procedures having been improved as a result of learning and feedback. Some of the policies we saw were either out of date or undated.

The provider did not provide any written evidence to show they had sought feedback from people and relatives about things which were working well and where improvements were needed.