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.
At our last assessment we rated this key question inadequate. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.
The service was previously in breach of the legal regulation in relation to good governance. On this inspection we found they were no longer in breach of this regulation.

This service scored 68 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The provider had staff newsletters that were distributed whenever there were changes within the organisation. This included areas around fire safety, apprenticeship week, new schemes for staff, approved suppliers and recognition awards. The provider’s action plans focused on learning and improvement and meeting minutes showed the provider’s overall goals. Staff felt there was a positive culture of collaboration. A staff member told us, “I feel like no matter what I say to management, seniors or deputies it is listened to. Some of the people tell me how much [manager] listens too. It opens up the door for new learning experiences in raising concerns.”

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. The manager was new in the service at the time of our onsite inspection however, they had already made a big impact within the service and had a lot of experience within the role. They had begun their application for the registered manager role to CQC.

Staff felt leaders were visible in the service and knew they completed audits for quality assurance purposes. The manager attended the service out of hours to complete spot checks on the staff and environment to ensure people received a positive experience consistently. A staff member told us, “For example the weekend just gone and previous months. [Manager] or someone will just turn up out of nowhere and they will just turn up unannounced to make sure everything is working in order.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had clear policies in place for people and staff to follow, their complaints policy was recently reviewed, and whistle-blowing policy was a clear process for staff to follow. Investigations conducted were thorough and prompt and lessons were shared with the work force while maintaining confidentiality. A staff member told us, “Managers promote an open and supportive culture. Staff can raise concerns through meetings, supervision, direct discussions, or the whistleblowing process and are encouraged to share ideas.” And “I’m able to bring up concerns to management without getting any repercussions. If I have a complaint against a staff member it would be kept confidential.”

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 promoted a positive culture around workforce equality diversity and inclusion. They ensured policies were in place to support staff that covered maternity/paternity leave, adoption, neonatal and bereavement leave. The provider had a flexible working policy in place.

The provider held drop-in sessions every couple of months for staff to come and raise issues to get them resolved. This included someone from human resources attending and meetings were held in working hours and out of working hours to enable staff that worked night shifts to come and raise concerns. The provider ensured staff had access to external counselling services that they could contact in their own time.

The provider did not always have embedded good governance oversight. We identified issues withs gaps of a person being repositioned who already was at high risk of skin breaking down. The provider advised they were aware of this although they failed to ensure the care plan reflected this known risk. We found another individual was at risk of urinary tract infections and staff were not monitoring their fluid. The provider told us they were aware of this but were unsure how to manage it but the persons care plan did not reflect this known risk. The provider implemented actions to rectify this.

However, the provider had clear responsibilities, roles, systems of accountability. The provider conducted regular audits within the service to identify and address issues. These included audits of people’s care plans, medicines and call bell times and Dining experience. Environmental audits were conducted including health and safety, infection prevention and control and handwashing. There were audits conducted from regional leaders. All audits had clear actions recorded with monthly entries of updates where some action had been taken but was still ongoing.

The provider ensured there were rotas planned to enable staff to know when they were working. They had a clear maintenance system in place to ensure that the building was maintained regularly. Notifications were submitted to CQC in prompt time frame. We identified the business continuity plan was limited and the nominated individual agreed with us and assured us this was currently being looked into across the whole organisation.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Although we received mixed feedback from some healthcare professionals we were assured from the provider, they were actively trying to improve this working relationship. We found in some people’s care plans advice given by healthcare professionals was recorded. We found the service supported other services in the community and people accessed the community. The provider identified an issue with their care planning software they used and were working with the provider to improve the product to provide clearer oversight.

The provider did focus on continuous learning, innovation and improvement across the organisation and local system. However, they did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people living with dementia. The provider did not always actively contribute to safe, effective practice and research.

The environment required improvement to ensure it supported people living with dementia to receive positive outcomes and healthcare professionals did comment on the dementia training within the service. However, the provider acknowledged and this and had plans to implement their dementia framework. We had requested to meet with the provider in a couple of months to discuss how the dementia framework was being embedded in the service. We found they had significantly improved in the service since the last inspection and had plans to continually improve the service going forward. The provider actively identified lessons learnt and ensured these were shared with the workforce.