Westbury Lodge

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. 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 legal regulation in relation to governance at the service.

This service scored 61 (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 always have a clear shared vision, strategy and culture which was based on transparency, equity, equality, diversity and inclusion and engagement. The provider had not identified that staff did not always ensure people’s rights, dignity and respect were upheld. For example, staff did not always knock on people’s doors or ask permission before entering people’s personal rooms. This meant people’s right to privacy and respect were not upheld. Additionally, we observed there was a board with pictures of staff who worked at the service. However, not all staff present had a photo on this board. This meant people may not have been aware or have a choice of who supported them. However, staff told us team culture and support had improved and that they felt listened to.

The provider did not always have 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 did not always have the skills, knowledge, experience and credibility to lead effectively. For example, leaders were not always alert to any examples of poor culture that may affect the quality of people’s care.

At the time of the assessment, leaders told us two people were sleeping in the lounge. We were told this was due to mobility needs, and that this was people’s choice. However, the service had not considered other alternatives for these people such as alternative accommodation. Additionally, there was no evidence the service had actively sought the views from the other people living at the service, or considered how this decision was in all people’s best interest, to ensure all people’s rights were protected.The registered Manager had completed a Mental Capacity Assessment for each individual sleeping in the lounge. However, these assessments did not consider that there was another person sleeping in the area or if they posed a risk to each other.

However, staff told us that they were supported well by managers, we were told that they felt listened to. Some staff said that the previous culture within the team was not good, however they felt that the current registered manager had addressed many areas and that this had now improved. For example, the manager had taken appropriate steps when dealing with staff conflict. One person told us,”[Registered manager] always listens”.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a freedom to speak up policy to support staff. Staff told us that they were aware of freedom to speak up and felt confident to speak up. One staff member told us,” I would be comfortable to escalate any concerns if I did not feel listened to”.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture among staff by improving equality and equity for people who worked for them. The provider had to support equality and diversity. Staff told us they felt supported by the provider. One staff member said, "We are well supported”. The registered manager told us about the developmental opportunities available to staff.

Although the provider had clear responsibilities, roles, systems of accountability, they did not always have good governance they did not always act on the best information about risk, performance and outcomes.

Some areas of risk had not been assessed using a holistic approach, control measures had not been fully explored and impact on all people involved had not been considered. For example, the restrictions of locking cupboard doors or using communal areas as areas for people to sleep had not been fully considered. This meant there was a risk of people being restricted within their own home.

Additionally, governance systems had not always been effective. For example, audits had not identified concerns relating to infection control, medicines, and health and safety.

The provider had also not followed the legal requirements of the Mental Capacity Act when making decisions on behalf of people who lacked capacity.

Managers and staff were not working in line with the Right Support, Right Care, Right Culture model and they could not assure themselves this guidance was embedded into the organisations knowledge and values. This meant there were gaps in leaders and staff knowledge about why it is important that guidance is followed. However, staff told us the registered Manager was responsive in addressing concerns raised by staff and was committed to making improvements.

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. Care records contained evidence that information was shared well with those involved in people’s care. The provider was in regular contact with other services to ensure care for people was consistent with their needs.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. The provider did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. There were occasions when people’s outcomes and quality of life were impacted by decisions made regarding the environment, risks and best interest of people.For example, we were told a kitchen cupboard containing snacks was locked. Leaders told us this was due to one person being at risk of choking. However, leaders had not considered alternative and less restrictive options to ensure people’s rights were protected. Additionally, we were told 2 people were sleeping in the communal lounge due to mobility needs and choice. Leaders had not considered creative and innovative ways to ensure quality of life for all people living at the service.. However, we saw that the provider shared learning during team meetings and supervision. staff were involved in huddles where information was shared. Staff told us information and learning from senior meetings was shared with them.