Westmoorland and Furness

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 the legal regulation in relation to good governance.

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 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 understand the challenges and needs of people in their communities.

The providers leadership culture was seen to lack direction, and questions about the service could not always be answered by the provider. Delegation of some managerial tasks had been assigned to the deputy care manager, who told us all it was her intention to submit an application to us to become the registered manager for the service.

Care staff that we spoke with could not tell us about the vision, or the values of the service. However, they did feel that there was a culture of collaboration with people, their relatives, care staff and the provider all communicating well together. A member of staff told us, “We all work well together, my clients and their families tell us lots of different things. I always make sure that I tell the office and let them know what people are saying.” Care staff knew the providers policies and procedures were available to them and knew how to access them.

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. The managers had the skills, knowledge, experience and credibility to lead effectively.

We were not assured that the deputy care manager was always given sufficient time to complete her managerial responsibilities to the best of her capabilities. Due to covering care hours when necessary.

People and their relatives, and care staff told us that the registered manager and deputy care manager were visible at the service, and they had confidence that leaders were knowledgeable and responsive. In respect of the deputy care manager one person told us, “I'm sure she takes things seriously and she does seem to get things put right.” Care staff told us that the registered manager and deputy care manager were knowledgeable, approachable and responsive. A member of care staff told us, “If I need advice, I know the office will always answer the phone; I'm never worried.” In respect of a safety incident one person told us, “I phoned management they came out straight away and went through it.”
 

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

We saw evidence that spot checks on care staff practice’s and supervision were completed, but not always in line with the frequency in the provider's own policies some procedures.

The provider had a whistle blowing policy in place, and all care staff we spoke to were aware of how to access this. A member of staff told us, “Yes, I know about whistle blowing; this is if I think another carer is doing something wrong and need to tell someone about it.”
The provider held monthly care staff meetings, and care staff were given the opportunity to make suggestions and voice concerns at these meetings.

The provider had implemented the use of a staff suggestion box so that care staff could make suggestions and leave feedback anonymously should they want to.
 

The provider value diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Care staff we spoke to talked positively about their experience of being recruited by and working for Westmoorland and and Furness. Staff told us they felt well supported by the management. A member of care staff told us, “The communication was very good when I apply for this job and I wasn't messed about.”

The provider told us that they supported new employees to understand cultural differences by discussing these topics during staff meetings.
 

The provider did not have clear responsibilities, roles, systems of countability and good governance. They did not always work in line with their own policies and procedures and did not use systems of oversight to effectively monitor the service.

The providers systems and processes were not always robust in identifying concerns or used effectively. We could not be assured that all information recorded was current, accurate or factual.

The provider had not assessed the risks around the safe use of anticoagulant medication. Some risk assessments lacked detailed or sufficient information for staff to manage risk safely. Risk assessments that we saw did not always identify the harm that could result from the risk occurring.

There was a lack of robust audits at the service. Audits carried out looked at a sample of people who used service, this meant the opportunity to identify themes or trends across the service as a whole was missed. It was not always clear that actions identified in order were acted upon, if they were acted upon, or if the actions were completed. An audit for falls that occurred at the service between September to November 2025, stated that 2 falls had occurred, however a report from the providers electronic care system was contrary to this. A medication competency provided to us post inspection did not appear to be applicable to this type of service.

We found care notes in relation to an accident contained conflicting information; one set of notes stated that no ambulance had been called and another identified it was called. Decisions taken in the best interest of people and consent around those decisions had not always been completed in line with the requirements of the MCA. A decision subsequently made using this process and provided to us during the assessment, contained information that was contradictory.

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.

The provider and deputy care manager displayed an open attitude to seeking and receiving support and were knowledgeable about how to access services. They told us that they had a good level of communication between GP's, the district nurse team and the single point of access team. Care staff supported some people who used the service to access the community. A person who used the service told us, “We do go out in the community, but I can have a day at the weekend if I want, I can ring up and ask for someone to support me all day Saturday.”
 

The provider 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.

We did not see any evidence of innovation across the service or creative ways in which the provider delivered care to improve the outcomes and quality of life for people who use the service. The provider did not always appear to learn from past events.

However, the provider and deputy care manager were involved with forums and attended meetings in a range of health and social care areas relevant to their roles such as registered manager network forums and safeguarding meetings. They also held memberships of several Health and Social Care organisation such as Skills for Care.