Westbourne 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 service 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 requires improvement. At this assessment the rating has changed to inadequate.This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

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

This service scored 36 (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. Staff told us the team worked well together and morale was good. We found a homely and welcoming atmosphere in the service. Daily handovers were undertaken by staff, to share information amongst the team. However, due to concerns we found relating to staffing, training, and managing risks, we could not be assured staff worked effectively to support people.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty. Whilst we found the provider listened to our feedback, there was a lack of transparency at times and we found some concerns which we were told had been addressed but remained a concern at the time of this assessment. We also found the management team were not always aware of incidents and events within the service.

Staff understood their responsibilities to whistle-blow on poor practice, and they told us they would be listened to by the management team. However, we could not be assured the provider always understood their responsibilities to report concerns to external agencies and.we found 2 incidents which we referred to the Local Authority’s safeguarding adults team during our assessment.

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. Staff told us they felt valued and supported in their roles. No staff told us they had been subject to discrimination. Staff received regular supervisions and were involved in regular team meetings. A staff member said, “My supervisions are regular and I feel able to bring anything up in these. The staff are all supportive of each other.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Governance systems were in place, to monitor the quality and safety of the service. However, these were not always effective in identifying concerns we found at this assessment. We found a lack of daily management checks, gaps in incident monitoring, and a delay in monthly management audits. This was due to a senior member of staff being on leave and the management team had failed to carry out these checks and reviews. Audits had failed to recognise concerns relating to managing risks, some medicines concerns, care plans, incident records, staffing and environmental safety. Whilst improvements had been made in relation to submitting notifiable incidents to CQC, we found 2 incidents which we had not been notified about.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. We could not be assured staff worked in partnership with professionals, due to concerns we found during this assessment. People told us they enjoyed accessing the community and activities on offer. People had their own mobile phones and were supported to keep in touch with family and friends. Relatives told us they could visit the service at any time.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.The service had no recent complaints or compliments. A quality improvement plan was in place and actions were on-going, including service refurbishments. However,several ongoing concerns and emerging concerns were found at this assessment.The provider gave us some assurances about the concerns we found during this assessment. However,these were vague and meant we could not be assured the provider understood their regulatory responsibilities.