Withins (Breightmet) Limited

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• 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.

The last time we rated well led, we rated it as requires improvement. At this assessment the rating has remained. This meant there needed to be improvement made to ensure there were robust governance arrangements.

The service was in breach of legal regulation in relation to good governance at the service.

This service scored 61 (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 purpose and objectives for the service which were based on 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 the provider did not have a specific vision and strategy document, nor did they have clear values by which they expected staff to adhere to. However, the provider did have a Statement of Purpose which contained their objectives and principles and were able to evidence impressive staff retention rates. The registered manager had experience of identifying the values within new recruits which suited the care home, and the residents and people corroborated this by telling us they were supported by kind and compassionate staff.

Staff and leaders demonstrated a positive, compassionate, listening culture which promoted trust and understanding between them and people using the service.

Leaders had a wealth of experience and credibility to lead effectively; however, they did not always have the skills and knowledge to consistently deliver their principles outlined in the Statement of Purpose.

The registered manager, who was also the Nominated Individual had a wealth of experience and credibility to lead the service. Their deputy manager and care managers also had worked in adult social care for several years and had the appropriate qualifications for their roles. Although this was evident, we did identify some gaps in knowledge and skills which we would expect the leadership team to possess, this included consent forms and capacity assessments not being in place and the care managers having not completed a medication competency assessment for several years, despite them completing them for the senior members of staff.

Leaders had not identified issues which we had during this inspection. Some of our findings were not in line with the services principles of care, outlined in their Statement of Purpose, including ensuring the home met the assessed needs of each person and that the needs of people were reassessed as frequently as necessary. The leadership team did not take a proactive approach to identify concerns within the service due to issues with their governance systems.

Despite that, leaders at every level were visible and led by example, modelling inclusive behaviours. The staff outlined how leaders were approachable and how they had no concerns raising issues with them. People, relatives, staff and external professionals were all complimentary about the leadership. An external professional stated, leaders went “above and beyond” for their residents and were genuinely interested in the people they supported.

The registered manager ensured leadership was sustained through safe, effective and inclusive recruitment and succession planning.

Leaders were alert to any examples of poor culture which may affect the quality of people’s care and have a detrimental impact on staff. They addressed these issues quickly.

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

Staff and leaders acted with openness, honesty and transparency.

Staff and leaders actively promoted staff empowerment to drive improvement. They encouraged staff to raise concerns and promoted the value of doing so. All staff were confident that their voices would be heard.

There was a culture of speaking up where staff actively raised concerns and those who did were supported, without fear of detriment. When concerns were raised, leaders investigated sensitively and confidentially, and lessons were shared and acted on.

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 registered manager had a good understanding of the equality act and explained the importance of protecting people who are vulnerable from discrimination.

The provider had appropriate policies for their staff in relation to equality, diversity and inclusion.

Leaders ensured their recruitment processes judged everyone on their merits and were not biased based on protected characteristics including age, sexuality or race. The registered manager evidenced the provider’s value in employing a diverse workforce by explaining the different countries staff had originated from.

Staff did not receive equality, diversity or inclusion training. However, the provider evidenced how almost half of the workforce had been enrolled onto different levels of National Vocational Qualification (NVQ) programmes which covered this topic.

Leaders made reasonable adjustments to support staff with physical or psychological difficulties. The registered manager explained how they would have regular check ins with staff, how staff may be allocated to areas of the care home which were less busy, how time off may be offered or advances in pay in certain scenarios.

Staff told us how leaders and staff treated everyone equally within the care home. Nobody reported instances of bullying or discrimination.

The registered manager explained they had little tolerance for bullying or discrimination and would act swiftly if necessary to discipline or remove staff. This was corroborated by staff and other leaders.

The provider did not have effective governance systems and did not always act on the best information about risk, performance and outcomes.

The provider did not have effective governance systems in place to ensure people’s consent to care and treatment was obtained, recorded, and reviewed in line with legislation. Oversight arrangements failed to identify that consent forms were not present in people’s care files, and that documents confirming agreement to care plans had not been signed by people receiving care. This demonstrated a lack of effective monitoring and auditing of care records. There was no assurance process to ensure capacity assessments were completed where required, or that best interest decisions were made and recorded when people lacked capacity and had no lasting power of attorney for health and welfare. The provider had not identified these issues through quality assurance checks or audits and therefore had not taken action to mitigate the risks. As a result, people were at risk of receiving care and treatment without valid consent. The provider was responsive to feedback regarding the concerns raised and has since implemented new consent forms which all residents have signed.

The provider did not ensure there were clear and effective governance, management and accountability arrangements in other areas. The provider had some quality assurance systems in place, but these were not always effective. The service conducted weekly medication audits; however, these had not picked up on issues found during the inspection. For example, staff were checking if PRN protocols were person centred and this was found not to be the case. We also saw gaps in audits for individual residents so could not be assured that the provider had oversight of medicines. Some audits were not up to date; this included the mattress and pressure relief cushion audit which was last completed in August 2025. Others were not completed consistently, including the residents room audits. The care plan audit consistently recorded that all necessary risk assessments were applicable, person centred and in date which we did not always find to be the case which suggested the checks completed were not thorough. Audits failed to demonstrate how areas which required improvements would be resolved and we did not see documentation which suggested reviews and analysis of audit findings were being completed.

The provider did not ensure there were robust systems to manage current and future risks in relation to the quality of the service. The provider did not have a service level risk register, and known risks were not formally recorded. Some of CQC’s previous inspection findings relating to medicines management, risk assessments and care plans had been identified again during this inspection. Incidents, accidents and safeguarding concerns were recorded, but thematic reviews were not being completed; in such a large service individual incidents and concerns can appear isolated, but themes reveal system failures which need to be addressed. The provider required better oversight of mandatory training compliance and whether care was being provided/documented in cohesion with people’s care records. For example, people’s weights, bowel movements and fluid intake was not always being accurate.

The provider ensured governance meetings took place. Although the frequency of these meetings was limited, there were various ways in which leaders and staff communicated including daily handovers and via a secure messaging application designed for businesses.

The provider needed to strengthen some of the arrangements for the availability of data as some records which were asked for were only identified following the onsite inspection. The provider did have plans to move onto an electronic care planning system which may support them having better access to data to monitor and improve the quality of care.

The provider ensured data or notifications were submitted to external organisations as required although we did identify a safeguarding concern which had not been raised with CQC. The registered manager acknowledged this as an oversight on their behalf and has since submitted this.

There was evidence of workforce planning and there were contingency plans in place for staff shortages, manager absence and increased acuity.

Staff understood their role and responsibilities and managers took account for the actions, behaviours and performance of staff.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners.

Staff and leaders were open and transparent, and they collaborated with all relevant external stakeholders and agencies. Partners were complimentary about the service regarding this, one professional stated how they had been involved with 2 safeguarding concerns (unrelated to the service) which had been raised appropriately by the care home. A further professional stated the provider was approachable, responsive and acted in a timely manner.

Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care. A professional who worked closely with the service, explained how they had worked in collaboration with them to accommodate a person into the service. They explained the provider’s persistent, committed, yet flexible approach to ensuring the person was able to settle into the service which had resulted in a better quality of life, less restriction, social support and stimulation.

The provider engaged well with the local authority and their contract and quality monitoring officer. There was evidence of regular meetings taking place which reviewed areas for improvement following CQC’s last inspection.

Staff and leaders engaged with the community. Residents were attending an Age UK music session once a month at a local church, they had recently completed a cohort of targeted strength and balancing sessions, a community exercise instructor attended weekly to conduct low impact exercises and the provider had links with local business, including a pub, who provided an appropriate set up and food when they visited. The provider offered ‘drop-in sessions’ for non-residents who mainly attended for the activities, for example a former resident, who is now able to live independently, regularly attended the service to engage in activities or to have lunch.

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

Leaders did not always have a good understanding of how to make improvement happen. The concerns which were identified at the previous inspection, had been identified again including the poor recording of topical medications, protocols for medicines which were to be administered ‘as required’ not always being clear and risk assessments and care plans lacking detail.

The provider’s evidence demonstrating how people, families and carers feedback was used to develop and evaluate improvement and innovation initiatives was limited. Although the provider captured some feedback via cards, emails, online reviews, via a secure social media site and through questionnaires, there was no evidence of the provider documenting how they had acted on the feedback, including no analysis of themes and no actions or improvements recommended.

The provider did review incidents and accidents, but there was limited evidence of lessons being learned from these events. The provider was not completing thematic reviews of incidents and accidents, so overarching themes were not being identified or shared.

The provider did not demonstrate a robust action plan. Providers are expected to have systems and processes in place, such as action plans following audits, complaints, inspections, internal quality reviews and incidents or safeguarding concerns to assess, monitor and improve the quality of the service.

Staff told us they were encouraged to speak up with ideas for improvement and innovation, and leaders actively invested time to listen and engage with them. There was a strong sense of trust between leadership and staff.

The provider had plans to adapt and extend the service and move to a digital care planning system. The plans for the extension involved the creation of designated activities space and the creation of safer, more accessible outdoor areas, for those who had impaired mobility or capacity.