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.

This service scored 62 (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 registered manager told us, “I would like each and every person in this care home to treat the [people using the service] with kindness, dignity and respect.” During the inspection, we observed staff engaging with people in a way that reflected these values. One staff member told us, “There has been lots of improvement. I don't feel like I'm being treated unfairly and we are always involved. Management speak to us with dignity - that makes a massive difference.”

Leaders did not always have the oversight or systems required to consistently identify, recognise or escalate concerns within the service. Gaps in internal processes meant that risks were not always reliably spotted or acted upon. Although leaders created an inclusive culture, their understanding of the service did not always translate into effective governance or reliable assurance which limited their ability to maintain safe and effective oversight.

Leaders were visible within the service and demonstrated understanding of the needs of people living in the home. Staff consistently described the registered manager and senior team as approachable and supportive. One member of staff told us, “They [leaders] are very visible. At night, [the registered manager] sometimes stays late and attends evening handovers. Her office is always open. She's very approachable and flexible.”

One family member told us, “The registered manager appears to be very supportive to her team. This makes it a good environment for the residents [people using the service]. I would not hesitate to speak to the registered manager if I had a problem.”

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

Staff reported feeling confident they would be listened to. One staff member said, “We are encouraged to speak up in handovers and meetings. If we have any concerns or anything to raise, we are encouraged to speak up.”

The Registered Manager told us, “I’m always available for them [staff] and I encourage them to talk to me.”

Clear whistleblowing procedures, aligned with national guidance, were available to residents, relatives, and staff.

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 staff team came from a wide range of diverse backgrounds, and everyone we spoke to said they felt comfortable and welcomed within the service.

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.

Although the provider acted promptly when we raised concerns during the inspection, their own governance systems had not identified these issues.

Systems were not always effective in identifying or addressing medicines‑related concerns. Although audits were taking place, they had not highlighted key risks such as medicines being given at the wrong time, lack of guidance for when required and variable‑dose medicines, incomplete records for thickened fluids, or unsafe use and storage of topical preparations. This showed leaders did not have sufficient oversight of medicines practice.

Governance systems were not effective in identifying gaps in people’s care plans or clinical risk assessments. Oversight processes had not highlighted missing or incomplete guidance in key areas such as diabetes management, continence monitoring, oral health, and behaviour‑related risks.

Environmental audits had not highlighted issues such as unlocked doors and areas of worn décor, and procedures intended to maintain a safe environment were not always effective in detecting these problems.

Governance systems were not effective in ensuring people’s rights under the Mental Capacity Act 2005 were consistently upheld. Oversight processes had not identified gaps in mental capacity assessments, conflicting information within best‑interest records or decisions being made without appropriate consultation.

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 held meetings with other services. The professionals we spoke to were positive about their partnerships with the provider.

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.

The provider had implemented some processes to improve the service; these were not yet fully embedded but demonstrated they were learning from the issues we found at our last inspection and working towards improvement

The registered manager engaged in professional forums and attended meetings across a range of health and social care areas relevant to their role. They also maintained memberships with key health and social care organisations, such as Skills for Care.

The provider had been collaborating with commissioning bodies to raise the standard of care and strengthen the quality of care documentation. Despite this, additional work was still needed to ensure that care plans, risk management approaches, medicines practices, and aspects of the environment were consistently robust. These areas required sustained improvement to ensure people received safe, reliable care.