Westside Nursing 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 Requires Improvement. At this assessment the rating has remained Requires Improvement. This meant that the governance processes did not always support the delivery of high-quality, person-centred care.

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

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders had set out expectations for staff behaviour and standards of care; however, these were not always consistently embedded in practice.

Leaders set a clear vision and positive culture. A charter of rights, statement of purpose including aims and objectives, were in place and clearly displayed. Expected values were set out in the staff handbook. A relative said, “Everyone says hello and has a smile when I visit.”

Managers were clear about the standards they expected. Team meeting minutes showed they identified areas for improvement and outlined how they expected staff to act, including challenging poor practice. However, assessment findings demonstrated that standards of care were not always met in practice. For example, there was not always a consistent culture among staff of showing empathy and understanding people's experiences. Interactions were task-focused at times, which limited meaningful engagement and did not always promote people's involvement, choice, and control.

Leaders were compassionate and inclusive. Leaders monitored the service and took action to improve the service though they had not identified and addressed the issues we found during this assessment.

People consistently praised the registered manager. A relative said, “[The registered manager] is so responsive.” Staff consistently told us that management were approachable and supportive. Team meetings showed clear communication between management and staff.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People said they felt able to raise concerns. No people who used services or relatives reported feeling unable to speak up. Staff were confident raising concerns with management and felt they would be acted upon. A whistleblowing policy was in place.

Team meeting notes showed evidence of staff being given the opportunity to speak up and drive improvement.

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. Policies were in place to support workforce equality.

Staff raised no concerns in this area and told us they were treated fairly by management. Staff surveys had been completed and discussed at a staff meeting.

Governance and management systems were not effective.

Governance processes were in place and there was a range of checks to monitor the quality of care being provided. However, these processes had not identified and resolved the issues we found at this assessment. These included shortcomings in environmental safety and maintenance, weaknesses in infection, prevention and control oversight, the application of the mental capacity act, activities provision and staff training and supervision.

We were told that representatives of the provider regularly visited the home but no documentation was available to demonstrate their oversight of the service.

The CQC rating was not clearly displayed on the Provider’s website.

Not all actions identified by internal and external audits had been addressed promptly. This included activities provision and clinical supervision.

Notifications were made to the CQC as required. A registered manager was in place. A business continuity plan was in place. Policies were in place but not all had been reviewed in line with review dates and an inappropriate restraint policy was removed and replaced with a new policy during the assessment.

Policies were in place regarding information governance and the use of information. However, staff did not always accurately complete care documentation.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

Staff worked effectively with external healthcare professionals and partner agencies to support people’s care and wellbeing. Information was shared appropriately to ensure continuity of care, including when people accessed other services.

Processes were in place to ensure suitable referrals to other community partners and agencies and had been appropriately followed by staff.

A professional commented, ‘We have had some miscommunication with one of the nursing staff in the past however I have been reassured that a process has been followed and improvements/support has been put in place for this not to happen again. Since then, there has been no concerns over communications.’

The service was committed to continuous learning and improvement. Staff completed a range of audits and areas for improvement were discussed at team meetings and through staff supervisions and appraisals. However, these processes had not identified and resolved the issues we found at this assessment.

The provider had been involved in research regarding falls management and had been accredited for their oral health. A professional commented, ‘All staff are always eager to improve and learn.’