Westerley 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. At our last assessment we rated this key question good. At this assessment the rating has changed to 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. The provider had not always promoted a positive culture and their processes to monitor the quality of the service were not always effective.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager had not always promoted a positive culture focused on staff wellbeing and mutual trust between them and staff. From our discussions with managers, and feedback from staff, we found staff did not always feel well supported and able to approach and discuss any concerns with their managers, and managers did not always recognise the need to support and trust the staff to fulfil their roles appropriately.

CCTV was operated in all communal areas and managers told us this was to see what happened when incidents occurred, such as falls, where the people may be unable to tell them. However,the business manager told us they were exploring different ways of monitoring staff competency, and this included a possibility of extending CCTV within the home. It was not clear how this would support a more positive staff culture within the service. They were unable to cite any evidence for why this was thought to be necessary, and the registered manager confirmed this had not yet been decided.

Most staff gave positive feedback about working at the service, but some gave feedback which suggested there was a poor culture where staff were fearful of speaking up. We were informed staff had been told what to say to inspectors. For example, staff told us they were advised by managers to say there were 3 staff at night and during our second visit staff did say this which we found was not true. Feedback to inspectors from 2 staff via email was identical and feedback from another 2 was very similar in content which may indicate they had been told what to say.

The registered manager and other managers were not always alert to the potential for a poor culture to develop within the service which may adversely affect the quality of people’s care and have a negative effect on staff. We received mixed feedback from staff about support from managers. A staff member said, “Sometimes they support but sometimes they don't.” Another staff member said they felt supported with providing care but not in other areas.

We were also told of numerous issues about staff treatment. A staff member said, “Management reportedly pressures staff to complete tasks quickly and reprimands those who take sufficient time to care for residents, adding to stress and dissatisfaction.” However, some staff were positive, 1 member of staff said, “I have asked for support and advice multiple times and have been supported many times by my managers.” We were also told, “They listen to staff issues, are personable, and offer clear direction as required.”

The registered manager was supported by a business manager and deputy who had the skills and knowledge to lead the service. People, relatives and professionals gave positive feedback about how the service was managed. A relative said, “The service is definitely managed well, the management are a good team. They are very approachable and always have time for you.”

Whilst we note the registered manager made arrangements to help meet people’s care needs, we were not always assured they took action to address concerns about the culture within the service and the support staff received.

People did not always feel they could speak up and that their voice would be heard.

The registered manager had a whistle blowing policy and a manager was identified as the freedom to speak up guardian. The registered manager, business manager and the deputy were related, which meant staff may be reluctant to speak up. To address this, staff were advised to approach CQC or the local authority if they felt unable to raise concerns with their managers. Apart from contacting statutory agencies, there were no other arrangements the registered manager had made to enable staff to speak to a more independent person, if they were concerned about the quality of care within the service.

Prior to and during the assessment, concerns were raised by staff directly with CQC. Whilst this meant the registered manager’s policy was, to a certain extent, effective, CQC tended to be contacted anonymously, suggesting staff were concerned about being identified. As part of those concerns, we were told of other staff who were reluctant to come forward to raise their own concerns. This meant we were not assured the registered manager fostered a positive culture where staff felt they could speak up and their voice would be heard.Following our inspection, we were told an independent person had been appointed as a wellbeing champion for staff to approach.

The registered manager had an equality, diversity and human rights policy and procedure and told us, “We have empowered staff to know about CQC complaints or the monitoring team.” Whilst we received mixed feedback from staff about working at the service, this meant they had followed the process as advised by the registered manager.

The registered manager’s processes for monitoring the quality of the service were not always effective. Whilst audits were completed, those we reviewed were all 100% compliant with no actions identified. Audits of people’s care records and medicines did not say how many or whose had been audited. The registered manager’s checks and audits had also not identified promptly where people’s fluid intake levels were low so action could be taken to address this shortfall.Following our visit, some earlier audits were provided which showed issues identified and action taken, such as the manager walk around audit in July 2025 found repairs required to carpet and flooring.

Whilst some notifications had been made to CQC, we found examples of unwitnessed injuries which had not been reported to other agencies and CQC as required.Following our visit, incident reports were sent to us which included additional information to explain how the injuries had occurred with a conclusion no safeguarding referral was required.

The registered manager’s trackers to monitor training compliance, complaints and incidents were not always effective. Staff mandatory training was monitored via a matrix. We found not all staff were included here and staff did not receive training on medical conditions people had, such as diabetes and epilepsy, so they understood how to care for them appropriately.Following our inspection, we were told the original matrix provided during our visit had not included all courses, in error. A new version was sent which showed staff had completed training in other medical conditions. This important document was not shared with us during our second visit when we queried whether all courses were included on the first matrix we received.

The registered manager’s original incident tracker lacked detail of action taken to help prevent re-occurrence; they were in the process of making improvements to this and had developed a new tracker which included existing mitigations and any further identified following the incident. There were numerous checklists used to ensure various health and safety checks were completed such as water temperatures and window restrictors to help ensure the premises were safe for people.

The registered manager understood their duty to collaborate and work in partnership with other providers and agencies, so services worked seamlessly for people. They shared information and learning with some partners and collaborated for improvement. Staff and leaders engaged with people, communities, and partners. A professional said, “The managers are always approachable and take on board any feedback.”

The registered manager was aware of the need for continuous learning, innovation and improvement across the organisation, but our findings during the assessment showed they had not been able to make continuous improvements at the service.

Whilst the registered manager had not identified areas for improvement we found during our assessment, managers were responsive when we informed them. This included attending to maintenance issues such as a faulty lock and arranging training for staff in dysphagia promptly. Managers had recognised the incident monitoring arrangements within the service could be further improved to evidence action taken and to analyse themes to prevent reoccurrence, and this was in progress. However, their quality assurance systems and internal processes to identify areas for improvement and learning, have not identified these areas in a consistent way, so there were continuous improvements within the service.

Notwithstanding the above, there were plans to refurbish the building with changes to the layout to improve people’s experience of care. We saw examples where technology supported oversight of care provided such as scanning of codes to offer assurance people’s needs were met in a timely way.