Westmorland Court Nursing and 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 service was in breach of legal regulation in relation to good governance as the systems in place to assess and manage the quality and safety of the service were not always effective.

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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

While there were systems in place to promote a shared direction and culture, such as an open-door policy, one-to-one meetings, staff meetings and equality and diversity training, improvements were required to ensure all staff felt valued and their hard work was appreciated.

Although all the staff we spoke to felt well supported by the registered manager, they did not always feel the provider understood the context in which the provider delivered care, treatment and support. One staff member told us, “Perhaps there could be more understanding above the [registered manager] level.”

However, staff spoke positively about the registered manager. One staff member told us, “[Registered manager] is very good. There is good communication from [the registered manager]. If we face any challenges, we can tell [registered manager], and they listen.”

Another staff member told us, “I sometimes feel my voice is unheard and that I cannot always go to leaders about how I am feeling.”

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

The provider had a whistleblowing policy which staff understood. Staff were able to report concerns in one-to-one meetings and the registered manager had an open-door policy. One staff member told us, “[Registered manager] is very helpful, and we can approach them without fear. I can talk to them about anything including any issues and how to address these.”

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 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.

Medicines audits had not identified issues with the application of medicated patches, safe storage of medicines, recording of medicines administration, lack of information in people’s care plans about as and when medicines, covert medicines, and topical preparations.

Governance systems in place to ensure the premises were safe to use for their intended purpose and used in a safe way, were not always effective.

Governance systems in place to ensure people’s behaviours and health risks were managed safely, were not always effective.

Governance systems to ensure there was enough suitably trained staff available to support people in a timely way, were not always effective.

The provider did not ensure arrangements to manage the integrity of data were robust. Information in several care plans and risk assessments was inconsistent or incorrect, and some care plans were missing. For example, when people had complex health conditions. Audits had not identified these issues.

Although the provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people, improvements were still required with how the service worked with partners to ensure health risks were shared when required.

The registered manager attended a management forum.

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.

Staff were encouraged to speak up with ideas for improvement and supported to develop their skills around improvement and innovation. Clinical staff had recently attended palliative care training, and the provider had booked staff on behaviour training facilitated by partner agencies.

The provider had worked closely with commissioners to improve the quality of care delivered and with care plans. However, improvements were still required in care planning, assessing people’s needs, supporting people with their risks, medicines and with the premises to ensure people consistently received safe and effective care, and positive outcomes.