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 inadequate. At this assessment the rating has remained 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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. We could not be assured that the service was well-led due to concerns found in relation to safe care and treatment, staffing, training, record keeping and governance. Similar concerns were identified at the services last assessment and although some improvements were made in relation to specific issues noted, the provider had not ensured staff understood their roles and responsibilities within the organisation to bring about significant and embedded improvements.

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. Roles and responsibilities were not clear within the service in relation to who should be leading improvements. Previous concerns raised with the service in relation to fire safety, staffing levels, medicines and training had not been addressed sufficiently and we could not be assured that the service was able to improve proactively due to the continued nature of the concerns found at this assessment.

Staff, people and relatives were able to speak up about concerns they had at the service. However we could not be assured that issues within the service were always reported on in a timely manner or that leaders understood their role in identifying and acting on concerns. For example, we identified multiple issues with medicines management but a recent medicines audit did not identify these concerns.[

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 were happy at the service and felt their managers were approachable and supportive. No issues relating to workforce equality, diversity and inclusion were identified during the assessment.

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. Significant concerns were identified with governance at the service. Audits were not always effective in identifying issues and we could not be assured they provided an accurate reflection of the quality and safety of care being delivered. For example, a medicines audit recorded checks had been completed and no errors had been identified; however, we identified several medicines errors and omissions. Governance checks were not completed consistently, and analysis of accidents and incidents did not consider all incidents recorded within the service. This meant leaders did not always have reliable information to identify risks, monitor standards and drive improvement.

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. The provider did not always work effectively with partners to share information, learn from feedback and drive improvement. Feedback from professionals was mainly positive, with partners describing the service as approachable and caring, and reporting concerns appropriately when required. However, we found the service did not always recognise or respond to risks through its own monitoring processes and records. This meant opportunities to work collaboratively with partners to address concerns, improve practice and achieve better outcomes for people were missed.

The provider had not demonstrated a consistent approach to learning, improvement and innovation. This was the service’s third assessment within the last 12 months, and concerns had been identified at each assessment. Although improvements had been made in some areas, the service had not demonstrated an ability to proactively identify, respond to and sustain improvements when risks were identified. For example, risks associated with choking had been reduced by ensuring staff had access to accurate information about the types of food a person could safely eat. However, other risks identified through internal monitoring and external feedback had not always been addressed. Concerns regarding staffing levels and the ability to safely evacuate the service during an emergency had previously been raised by CQC and the fire service but remained unresolved. The service had introduced medicines audits following previous concerns; however, these audits were not effective in identifying issues and did not provide leaders with reliable information to drive improvement. We could not be assured the provider had embedded effective systems to learn from feedback, identify risks independently and make sustained improvements to the quality and safety of care.