Whitgift House

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 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 as we identified gaps in documentation and record keeping which meant we could not be assured they were maintaining accurate records for robust and effective oversight.

The provider was in breach of legal regulation relating to governance. We have asked the provider for an action plan in response to our concerns.

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 shared vision and values, and leaders were beginning to re-establish a positive and inclusive culture which had been impacted by recent management changes.

Some staff and people reported inconsistencies in communication and whilst there was evidence that improvements had been identified, actions had not always been implemented in a timely way. Leaders recognised this and had started to take action to stabilise the culture and described how they planned to do this.

A new home manager had recently been appointed and had set clear intentions to improve practice, strengthen staff culture and reintroduce structured ways of working. For example, leaders described plans to strengthen and re-introduce processes such as a daily Heads of Department meeting to strengthen person-centred care.

Staff described a caring culture where people were supported with dignity and respect and relationships were valued. People’s feedback supported this, with one health professional describing a “warm, friendly atmosphere” where “nurses, carers and staff are kind and caring”.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty although leadership arrangements were still embedding following recent changes.

The newly appointed manager was experienced and visible within the service on the day of assessment, meeting residents and families, and providing oversight of care delivery.

Leaders promoted an inclusive approach and described an intention to “lead from the front” and be part of the team, encouraging staff wellbeing and recognition through initiatives such as an open-door policy, staff rewards and cultural awareness events for both staff and the people who lived in the home. Staff told us they felt supported by senior leaders. One staff member said, “I feel very comfortable and free when speaking to senior managers.”

However, leadership was still developing following a period of management changes. Some staff, people and relatives were less familiar with the new manager and expressed a desire for more visible leadership and engagement on the floor. This showed leadership capacity was improving but had not yet fully embedded across the service.

The provider promoted an open culture where staff were encouraged to speak up and raise concerns.

Leaders had established processes to support this, including a designated “speak up” lead. The manager described an open-door policy and emphasised treating feedback confidentially to empower staff to feel safe to raise concerns. They also demonstrated responsiveness by giving an example of how they were responding to and acting on a recent concern.

Staff confirmed they were able to raise concerns and that these were usually listened to and escalated appropriately. This reflected a culture where speaking up was supported.

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 had systems and practices in place to promote equality, diversity and inclusion for the workforce. Leaders recognised the importance of inclusion and described plans to strengthen this area, including introducing regular cultural awareness events and providing additional equality, diversity and inclusion training.

Staff were supported through training and wellbeing initiatives. Leaders also acted when concerns arose relating to inclusion.

Policies relating to equal opportunities and staff support were in place and up to date.

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.

The provider had multiple (digital and manual) processes that were difficult for staff to understand. The provider used these for both organisational governance and to measure the service’s performance. As a result, we found this led to recording gaps, and it was not always easy to establish if all actions were identified and consistently taken to address all the risks these different processes identified. For example, we reviewed infection prevention audits which lacked clear follow up to ensure actions identified were completed in a timely manner.

We found that the electronic care record system provided data on incidents such as individual falls, and individual actions were recorded. However, there was limited evidence that data was consistently analysed to identify trends and prevent recurrence. While individual incidents were recorded, we did not see evidence of analysis to inform service-wide learning.

Records were not always accurate or kept up to date. For example, we identified gaps in recruitment processes, including a risk assessment, expired professional registrations, and incomplete records. This meant safe recruitment practices were not consistently followed. We provided feedback to managers who took immediate steps to ensure these checks were updated and reviewed, and we have confirmed these actions have been taken.

This was a breach of regulation in relation to governance.

We identified gaps in governance, including a failure to submit statutory safeguarding notifications to CQC in line with requirements

Given the inconsistency and gaps in record keeping we could not be assured the governance processes were always used effectively to minimise the risk of harm to people. Leaders acknowledged these issues and had begun to act through a service improvement plan and strengthened oversight. However, governance systems required further development and oversight to ensure they were robust, consistent and effective in driving improvement.

The provider did not always work proactively with partners to improve outcomes for people. Although there were examples of partnership working, this was not consistently embedded across the service.

The service worked well with healthcare professionals, including GPs and therapists, who described staff as supportive and collaborative. However, feedback also indicated the provider did not engage regularly with all external partners. This limited opportunities for shared learning, innovation and system-wide improvement.

Some activities were supported by young adults from the college, and there were shared activities with people who resided in supported living although there were limited opportunities for people to engage in activities outside in the local community.

Leaders recognised the need to increase their activities programme and strengthen partnerships and had plans to engage more with more partners externally. These actions were at an early stage, and had not yet resulted in consistent improvements.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

While processes for learning were described, including weekly meetings and audits, these were not consistently embedded. There was limited evidence that information from incidents and audits was analysed to identify trends or drive preventative action.

The manager acknowledged this and stated that audit trails and evidence of learning needed to be strengthened, with a focus on understanding why issues had occurred and how to improve practice. Although some improvements were being introduced, such as regular incident reviews and enhanced monitoring of care records, these were recent and had not yet demonstrated sustained impact. This meant opportunities for learning and continuous improvement were not fully realised.