West Wood 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 newly registered service. This key question has been rated 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 governance at the service.

This service scored 29 (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 expressed our concerns that the ‘Memory Floor’ did not currently provide an appropriate environment for people living with dementia. However, the management team told us they did not believe in having different coloured doors etc. They also told us they did not have things like memory boxes or tactile items because of infection control risks. This meant the provider was not working in accordance with evidence-based advice and guidance provided by dementia specialists, in respect of creating dementia friendly environments.
 

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.

A person’s representative told us that agreements and promises had been made by the provider prior to and upon their loved one’s admission to the home. However, they said there had been a few issues during the year and told us things had not been handled well and had caused the family and their loved one “Great stress”. This representative also told us, “There has been almost a revolving door of changing staff, with interim managers you hardly saw or appeared very defensive if you could nail someone down to ask them something. It was unnerving and we were kept in the dark.”

A person’s representative also told us, “It would seem that about 60-70% of the staff have disappeared without reason. All we got was a letter telling us that [previous manager] had been relieved of her position and there would be a replacement. We were not kept informed.” And, “The [senior management] stepped in at one stage and managed to upset both family and staff.”
 

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

We looked at some of the responses people had received from the management team at the home and found that these were sometimes defensive and lacked empathy or compassion. In addition, investigations into complaints sometimes lacked substance and sound evidence.

A person’s representative told us, “I did raise my concern about staffing levels and training during the open meeting 2 months ago with the new manager, but the response I got was ‘All these things are being looked at’”.

Another representative explained, “I have now spoken with the new manager, but [they are] the third [permanent] one, but there have also been interim managers appearing. I seem to remember there was [senior management] on site at one stage but [they] didn’t engage and was very defensive.” This person added, “Things have improved slowly over the last few months, but there is still an element of box ticking.”

A third representative told us, “It would be nice if the goals to improve things were measurable rather than being told it is being dealt with. It seems at times that there is more focus on finding out whether I am going to attend the Christmas meal, rather than on improvements.” And,“Communication could be improved.”
 

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We raised concerns about some staff working excessively long hours. The management team told us this did not happen and said that the evidence they had provided us with, by way of rotas, was inaccurate. However, feedback from staff, together with our observations and a further review of the rotas, together with the electronic staff signatures on people’s daily notes compounded our concerns.

Staff told us their rotas were often changed and overtime shifts added at short notice, which made it difficult to balance home and work life.

A member of staff told us, “While I try to do my best, I have sometimes felt unsupported, particularly when I am asked to work shifts I was not informed about in advance. I would feel more supported if communication and respect for agreed days off were improved.”

Another member of staff told us, “I am leaving the job as there was no flexibility with working hours. I was recently told my hours would be changed and, as this did not fit in with my personal commitments, I had to make the decision to leave.”

A member of staff also said, “I enjoy supporting the residents, but I feel staff should be treated fairly and with respect. Improvements in communication, rota management and support for staff would help us provide the best care.”
 

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.

The provider’s quality assurance systems at service and provider level failed to identify some of the issues found during this inspection. Where the provider’s quality assurance systems had identified issues at the service, appropriate action had not been taken in a prompt and timely manner. This meant the provider could not ensure that the quality of the service was being maintained and the regulatory requirements were being met.

For example, senior management carried out a regional audit in August 2025, which was scored ‘Amber’ with 87% compliance. There was only 1 area raised in the action plan summary. However, some of the areas scored ‘green’ as compliant were inaccurate and some areas were marked N/A or ‘not looked at on this occasion’. A further regional audit was carried out in November 2025, which was scored ‘Red’ with 65% compliance. On this occasion there were 20 areas requiring action raised in the action plan summary. Some of the areas within this audit highlighted shortfalls, which had not been identified previously and some areas remained ‘not looked at’.

We reviewed copies of the daily handover notes. We found these to be excessive, cumbersome and ineffective. The handover reports were comprised of full daily notes for each person from the previous shift and only the senior staff attended the handovers. The senior staff were allocated 15 minutes to complete the handovers, which was insufficient time to review all of the information recorded.

The provider failed to consistently ensure and maintain an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.

We also identified the electronic care planning system was not currently fit for purpose and staff at all levels were not competent in using it.

We identified that people’s nutritional records were of a very poor quality. They were not recorded in real time and did not accurately reflect what people had to eat or drink during the course of the day. There was a lack of monitoring with regard to what and when people were actually eating and drinking and there were no effective audits.

For example, people’s entries for food and drink were sometimes duplicated with information being recorded at different times of the day. It was not possible to determine what times people had actually received food and drink and there were consistently long gaps between the last meal and drink of the day and the first meal and drink of the following day. On some days it appeared that people may have only had only had 1 or 2 meals and some days there were no entries at all. There was no system in place to identify these shortfalls and ensure people were being provided with adequate food and drinks.

During the weeks of our assessment, we found there were gaps where the daily heads of department meetings had not happened. In addition, although these meetings usually included every department at the beginning, after people such as the kitchen, housekeeping and wellbeing staff had given their daily report, they left the room. Senior care staff then briefly discussed the wellbeing of people living in the home. This was not an effective way of sharing information, as kitchen, housekeeping and wellbeing staff were not included in discussions about people that may involve or be related to their departments, such as if people were not eating well, had issues with personal hygiene or infections or were low in mood.
 

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 found that the provider involved other health professionals, when necessary, but referrals were not always made in a timely way. Information and guidance from other health professionals was also not always shared appropriately with staff to ensure people’s needs were met.

A person’s representative told us, “The SALT team visited [Name] in hospital regarding [their] swallowing issues, but communication wasn’t forthcoming [once back at West Wood].”

We also found that effective partnership working was impacted by staff and management turnover. A health professional told us, “I think one of the biggest problems is the lack of consistency with staffing.”

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 provider and management team had failed to appropriately identify and address shortfalls in the quality of the service. Where changes were made, these were not continuously monitored and reviewed, to ensure improvements were embedded in the service.

We also identified that the provider and management team did not work in accordance with evidence-based advice and guidance, such as that which is provided by dementia specialists and the National Institute for Health and Care Excellence (NICE).