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 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 provider was previously in breach of legal regulations in relation to governance. Whilst we found improvements had been made, further work was required, and the provider remained in breach of this regulation.

The provider was previously in breach of the legal regulation in relation to notifications. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.
 

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 shared vision, strategy and culture for the service but lacked a fully developed culture of continuous improvement for the service.

The provider’s vision aims and objectives for the service were clear within their statement of purpose. Whilst their aim was to provide high quality care, there was a lack of evidence to show how this was to be achieved. As a result, the work to address the required improvements from the last inspection was only partially complete. The provider was not able to demonstrate there was sufficient oversight of the service in order to both create and drive a culture of continuous improvement for people.

However, following our feedback, the provider started to compile their plan. They also provided evidence they have made staff aware of the priority areas they need to address, for example, in relation to record keeping. Policies were in place for staff's guidance.
 

The provider’s management of the service lacked the consistent level of attention to detail and structure staff required. All staff did not have clear information, with robust systems to follow, underpinned by clear expectations for all roles and effective oversight of their work.

The provider spent a lot of time on-site working alongside the staff team supporting the provision of people’s care. However, this impacted their ability to commit sufficient time to their duties as both the registered manager and provider, to ensure robust management oversight and full compliance with all regulations. In order to fully progress and achieve all of the required service improvements identified.

The provider had a head of care and senior care staff to support them in their role and to share management tasks, however, they were not fully utilised. For example, senior staff were not used on each shift to ensure all records were checked for completeness, to enable any gaps in incident reports, fluid, re-positioning, medicine and body map records to be identified, reported and addressed. Although the provider has started to act in response to our feedback, this will take further time to complete and embed.

The provider had completed training on the use of their electronic care planning system but was not aware of its full functionality and how this could be utilised, both to support staff’s daily work and their governance of the service. For example, with the production of reports to aid analysis.

The provider led in a caring and person centred manner. They were committed to the people cared for and their staff team. Although they had led improvements since the last inspection, they were not systematic in their approach.
 

The provider fostered a culture where staff could speak up and their voice would be heard.

The provider’s statement of purpose and whistleblowing policy provided guidance to staff about whistleblowing and how to raise concerns. Staff’s views were also sought through their supervisions and the staff survey. The provider worked alongside staff in the home during the week and was accessible to staff whether they were on or off site. Staff had the opportunity to speak with them in person and felt they could do so.
 

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.

There was diversity within the workforce. Staff were supported within their roles and reasonable adjustments were made if required to enable them to carry out their work. Staff said they felt treated fairly. Staff said they had opportunities for professional development if they wished.
 

The provider did not have clear responsibilities, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

The provider lacked written systems to enable them to maintain and demonstrate their oversight of the service and to monitor progress against identified actions. For example, there was a lack of systems to demonstrate when utility checks were due, to evidence oversight of environmental safety documentation, daily records checks, or staff recruitment record checks and supervisions. Although the provider was aware of the need for systems and had secured external administrative assistance for this purpose. It will take longer for the provider to complete and embed this work.

The provider lacked a systemic approach to determining what areas of the service to audit and when. Therefore, it was not clear what audits took place and how often. A number of areas were not audited, such as care plans, risk assessments, daily records, and staff records. Therefore, there was a risk omissions in records would be missed.

The provider completed some audits and actions were identified. However, they lacked detail regards who was responsible for actions and by when and there was not a process to check and confirm actions had been completed. The provider has since our feedback informed us of the action, they have taken to identify an electronic audit system which they plan to use to structure their audit processes.

The provider’s last inspection report was displayed on their website as legally required but the copy within the home had not been changed. We brought this to the provider’s attention, and they have stated this will be addressed.

We did not find evidence that the above concerns had negatively impacted people or their experience as the provider and staff worked well as a team and communicated well about people’s care and the management of any risks.

However, the provider had since the last inspection informed CQC of notifiable events as required. They have a business continuity plan and policy in place to manage emergencies.
 

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The provider worked in partnership with a range of health care professionals, who provided positive feedback about how staff worked in collaboration with them to support the safe delivery of people’s care.
 

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

The provider was unable to demonstrate they had a plan of how all the required improvements were to be achieved, by whom and by when. There was a lack of written information about the measures they would use to evaluate whether the improvements required had been achieved.

However, they appreciated the need to seek assistance to support them to make the required improvements and they had made an external link who could support them with quality improvements. They also made use of their registered managers network, in order to seek support and guidance. They had also arranged a source to provide some external administrative support following the last inspection.

The provider told us they had started to appoint staff as champions to lead progress in different areas. They had appointed and trained both dignity and infection control champions. This required further work, to ensure staff were appointed and leading work in all key areas and that resulting improvements were being made for people.