Westroyd Care 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 service since it was registered under the new provider. This key question has been rated requires improvement. This meant people’s needs were not always met.

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 providers vision, strategy and culture were not consistently adopted. People’s inclusion and engagement were not always recognised by some staff. The challenges and needs of people were not always understood.

People’s views were mixed as to whether the culture of the service was supportive of their individual needs and choices. Whilst some people told us they made day to day decisions, others said they felt they had to justify and explain their choices to staff. A person told us, “Everything gets questioned, if I want to go upstairs, they ask me why. I don’t like that.” Others spoke positive about the friendliness of the service. A person told us, It’s lovely here. I have nice friends and the staff are lovely.”

We found improvements were need to the culture and inclusivity of the service, to ensure everyone using the service felt engaged and had their needs met. For example, many family members spoke of the lack of opportunities for their relative to access the local community, and of the limited activities which their relative could engage in.

The senior management team spoke of their vision, values and strategy for the service, both for the present and future. They spoke of the changes they had made since they purchased the service several months ago. Managers spoke of continued investment and support of staff through training and supervision to support staff in the delivery of high-quality, person-centred care. The provider had structured planning in place to move the service forward, in line with their key values, which included integrity, team working and partnerships, and wellbeing.

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.

Family members were positive about the approachability of the registered manager, management team and staff. A family member said, “I like the managers management style, and the deputy is good, they make a good combination.”

Staff told us the management team led by example. A staff member told us, “I think they are professional and work to a high standard.” Staff expressed confidence in the ability of the registered manager to monitor the service and make improvements. A member of staff us, “The manager has a good level of knowledge, and monitors everything, and would take action where needed.”

Staff spoke positively of the registered manager and management team; they told us they were both visible and approachable and had a good understanding of the needs of people and the service. A staff member said, “Relatives, people and staff know where the manager is, their office is on the ground floor, the door is always open, and people feel happy to approach.”

Records confirmed staff were supported in their development through regular supervision and appraisal, and staff confirmed their competency was assessed for tasks related to the delivery of personal care.

The area manager made themselves available to support the registered manager with the inspection. They spoke of their plans for the future of the service and the wider organisation and remained open and transparent about things they felt still needed to be improved.

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

Staff were aware of the provider’s policies and procedures which supported them to raise any issues relating to poor practice, concerns and complaints. Staff told us they felt safe and comfortable to speak out. A member of staff told us, “I would report any bad practice and know it would be dealt with.”

Staff meeting, supervisions and feedback surveys provided staff with opportunities to share ideas. Minutes of meetings and the outcome of staff surveys evidenced staff were confident to speak up, and that their views and ideas were heard.

The registered manager informed us staff had access to a confidential call system to enable them to share concerns anonymously.

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’s policies and procedures supported equality, diversity and inclusion in the workforce.

The registered manager understood their responsibilities in line with the Equality Act 2010 and its implications for employees. The registered manager was aware of their role in upholding the principles of the Equality Act. They informed us the implementation of the provider’s policy and procedure for equality, diversity and inclusion was monitored through internal reviews and quality audits.

Staff surveys, supervisions and meetings were used as a mechanism for monitoring diversity and inclusion, and responding to issues raised. Staff received training on equality, diversity and inclusion as part of their induction and ongoing training. Staff told us the registered manager, where practicable, supported staff with flexible working, which included enabling staff to work specific shifts based on their caring responsibilities. Staff said the registered manager treated staff equally and without favouritism.

The registered manager was aware of potential adaptations which could be considered to support staff. For example, safe spaces for staff, and additional breaks for individual members of staff, where required based on personal circumstances.

The provider had clear responsibilities, roles, systems of accountability and good governance. They acted on information about risk, performance and outcomes and shared this with others when appropriate. Improvements and changes made in response to internal auditing were not always embedded to ensured sustained improvement.

Family members acknowledged some improvements had been made in response to their feedback. For example, plans to organise a day trip. A family member said, “I believe there is a boat trip planned, and on big occasions they celebrate things, such as V.E. Day.” However, many family members said improvements were needed to the frequency and scope of activities. Many family members as previously referenced within the report felt they weren’t listened to as issues they raised had not been addressed. For example, improvements to the driveway.

Audits had identified areas for improvement, which included the quality and accuracy of care records. “However, we found areas identified by the management team for improvement had not been fully embedded. For example, improvements to the consistency and content of care records, and increased opportunities for people to engage in recreational activities.

The senior management team and registered manager acknowledged further improvements were needed, and they had already introduced some changes following our initial feedback. For example, the development of a more person-centred care plan for people in receipt of end-of-life care, more in depth recording of people’s dietary and fluid intake, and the follow up actions required by staff to improve quality outcomes for people where people were at risk of dehydration and malnutrition.

A range of audits were undertaken by the area manager and registered manager, underpinned by oversight and monitoring by the provider in the form of clinical governance meetings, heads of department meetings, health and safety meetings and the monitoring of key performance indicators.

The providers and registered managers commitment to driving improvement meant the outcome of both internal audits and reviews carried out by external stakeholders and partner agencies were shared with staff, this included what was working well and the areas required for improvement.

The provider did consistently support collaboration and working in partnership with people using the service and their representatives. There was limited partnership working with community services to support quality outcomes for people.

Some people’s feedback did not fully support there was collaboration between themselves and staff, they spoke of being asked to provide explanations for some of their choices. People had limited links with the community as people had few opportunities to go out, unless supported by family members to do so. This restricted their integration into the wider community, for example by attending community groups, activities or event such as dementia café’s.

People expressed satisfaction with their care overall when we asked them if there were any improvements the service could make. A person told us, “I can’t think of anything to do better here.” Another person said, “I can’t think of anything to improve the home. They help me enormously.”

Family members had opportunities to develop and improve the service through meetings and regular surveys, and family members confirmed minutes of meetings were shared with those who were unable to attend. However, some expressed dissatisfaction as the time it took for action to be taken in response to their feedback.

Family members, including some of those who had spoken of improvements they would like to see introduced, told us they would and had recommended the service to others. A family member said, “I have already recommended the home.” Another family member told us, “Definitely recommend it, it’s such a nice home. 9.5/10, staff are great.”

Family members confirmed staff worked collaboratively with external organisations to support good outcomes for people.

We asked an external health care professional whether staff from their service were invited to be involved in key decisions about people’s care where appropriate. They told us, “Yes. I am involved in key decisions when needed, such as end-of-life and palliative care discussions, and in reviews of residents’ care plans. In some cases where next of kin live abroad, staff have arranged multi-disciplinary meetings that include family members remotely, ensuring good communication and shared decision-making.

The registered manager informed us the staff team worked collaboratively with partner agencies, such as healthcare professionals, local authorities and sharing information during multidisciplinary meetings and care reviews, and that this approach enabled the staff team to learn from wider expertise and ensure co-ordinated support for people.

The registered manager was aware of the need to inform key stakeholders, including the Care Quality Commission (CQC) of events and incidents. The registered manager had a good understanding of their responsibilities around health and safety, the overseeing and reporting of safeguarding, quality assurance and risk management.

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 sought feedback from people, their family, staff and other key stakeholders about the service provided.

Our discussions with people and family members identified areas where improvements could be made to support the outcome and quality of life for people, which focused on increasing activities and recreational opportunities both within and external to the service. The senior management team and registered manager acknowledged this as an area for development and told us they were looking to increase activities. However, there was no formal plan of action as to how this was to be achieved, or whether any additional resources would be provided to bring change.

The registered manager informed the provider had invested well since taking over the service in December 2023. This included an uplift of the building through purchasing of new equipment, investing in staff, including financial renumeration, and a commitment to increase the quality-of-care people receive.

External agencies informed us representatives from Westroyd Care Home attended provider forums organised by the local authorities, where updates and contract information was shared.