Westcott House Nursing 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.

This is the first assessment for this newly registered service. This key question has been rated 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 at the service.

This service scored 54 (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. They did not always clearly understand the challenges and the needs of people and their communities.

We received feedback from some staff that they did not always understand the vision of the service. These staff told us they struggled to communicate with some of their colleagues and felt they could not speak to the provider about this. We discussed this with the registered manager and the provider who told us that they had already started looking at how they could improve the culture by instructing a consultant and recruiting a quality assurance manager. We saw that this was in progress, but further time was required to embed the culture fully in the service.
Other staff told us they understood the strategy of the service and that there was generally a positive culture in the service.

People and their relatives told us there was a positive culture at the service. Comments included “It’s lovely here”, “It’s a good place to live”, “It is very nice, caring and they do their best. Very welcoming to family and friends” and “I would recommend, all is good so far, so good. I am very at ease.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Whilst the provider had identified areas of improvement in relation to the culture of the service, some staff and leaders did not always understand why it was important to ensure people’s preferences were respected and how to ensure people consistently received dignified care. The provider and registered manager were very responsive throughout the assessment, and clarified that this was not what they expected, and they immediately undertook observations of mealtimes and increased staff presence on the relevant floors to reduce the risk of isolation. Other staff told us leaders were approachable and capable. One member of staff said, “We can always ask a senior and we always feel supported.” Another member of staff commented, “[Registered manager] is [a] well organised person and kind and very supportive moreover approachable person.”

People and their relatives told us the service was managed by capable and compassionate leaders. One relative told us, “I would recommend the home highly.” Another relative commented, “I know [registered manager], lovely lady. I would say that if anyone had the same problem as [person], come to Westcott.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. However, not all staff felt they could speak up.

Staff told us they did not always feel able to speak up about certain areas because they did not always feel heard by the provider. Comments included for example, “I don’t even speak up any more, it goes in one ear and out the other”, “We try to explain to them (management) about residents but sometimes I feel they are not listening to us” and “I feel that many decisions are controlled by the owner, including staffing and rotas. While [registered manager] works hard, I feel there are limitations in decision-making.”

Other staff felt heard and told us, “We (staff member and registered manager) have a good relationship, if there is a problem I will go and see her.” Another member of staff said, “Management are approachable, supportive, and willing to listen to staff concerns and suggestions.”
People and their relatives told us they felt able to speak up if they had a concern. A relative told us in response to raising concerns with the provider, “Yes, I think so. People are very, very friendly.” Another relative commented, “Absolutely [I would raise a concern].” A third relative said, “[Registered manager] is very approachable.”

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. However, further work was required to ensure all staff felt as part of the team.

Whilst there were areas we have highlighted in relation to equity, the registered manager and provider told us they were aware of their responsibilities to ensure there was an inclusive and fair culture at the service.

Staff had undertaken relevant training to ensure they understood their responsibilities towards each other and the majority of staff told us they felt supported by their line manager. One member of staff told us, “Staff get all the support and guidance whenever it is required.”

The provider told us they took action to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion. They had involved external partners to help them change the culture in the service but there was further time required to embed this consistently across the service, so all staff felt as part of the team.

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.

Governance systems were not operating effectively as they had not identified the significant shortfalls found within this assessment, The provider and registered manager were responsive to our concerns and feedback, however, services are expected to have reliable systems in place to always ensure the safe operation and this was not always the case.

Where we identified areas of improvement during the assessment, as highlighted in this report, the registered manager and provider actively sought to make improvements as soon as this was possible by acknowledging the concerns and actively addressing them. During the course of this assessment, the registered manager updated their audits to include the areas we highlighted in other sections of this report. They also shared areas of good practice with other care homes they were operating, and they sent us evidence of the improvements that had been made and the new systems they had introduced. We will request action plans and updates to ensure improvements are introduced, progress is made and these are embedded.

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 collaborated for improvement.

Partners told us the service worked well with them and took feedback on board, and staff effectively shared information with partners in healthcare and the local community. The provider understood the importance of working collaboratively and we saw from care records that external partners had been involved in people’s care and staff communicated with them effectively. Relatives and external partners also confirmed this. One partner told us, “When I visit the nursing home, the staff take time to provide feedback about patient presentation and their concerns, and they work well with our service to improve the patient’s mental health and address any concerns.”

Records showed staff worked in partnership with their local community. For example, staff organised dementia awareness walks, community singing, faith services and intergenerational visits.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. However, they did not always identify areas of improvement until we undertook this assessment.

There was a culture of learning and improvement at the service, and the provider understood their responsibilities to continually improve the service. We found the registered manager and provider took our feedback very seriously and they had made significant improvements to the service environmentally since taking over the service. However, there were further areas of improvement as we have highlighted in other sections of this report which were prompted solely by our assessment. One relative told us, “The new ownership has brought positive change. There is a consistent plan of improvement. Both indirect and direct. By indirect, it’s the environment they are improving and by direct, it’s fewer agency and more consistent faces staffing wise.” An external partner told us, “Since the new management team has taken over, there have been noticeable improvements within the service.”