West Ridings 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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection we rated this key question requires improvement. At this assessment the rating 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 provider was in breach of legal regulation in relation to the governance of the service.

This service scored 32 (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.

The findings from our assessment indicated the culture of the home was not person-centred. There were instances were people’s basic care needs were not being met adequately or in line with their preferences. The provider had not created a culture where the team worked well together and learnt from incidents which meant people did not receive good care.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Leadership and management at the service was not effective. The provider had failed to act on the issues impacting the service in a timely manner. There was currently no registered manager in place. They had left their employment several months ago. The provider had brought in an external manager consultant to oversee the home moving forward. They were in the process of recruiting new management. The lack of continuity in the leadership had impacted on the care people received and staff’s morale.

Staff told us they did not feel confident that concerns raised to managers would lead to action being taken.

Most people and relatives told us they did not know who the manager was. Their comments included, “I don’t know who the manager is” and “I don’t know about the managers.”

During our assessment, we found the management team took action on the issues we raised, however the provider could not demonstrate that an effective and responsive management team was in place. The lack of effective and consistent management oversight placed people at risk.

The management team had not fostered a positive culture where people and staff felt they could always speak up and feel confident their voices would be heard.

Most of the people had not felt a need to raise a complaint, but relatives raised some concerns and did not always feel these had been investigated and action taken.

Some staff told us they felt they were able to speak up, however they were not assured action was taken when they did speak up.

We reviewed the provider’s service improvement plan and there was no indication that concerns raised by staff had been captured and followed up. For example, staff raised concerns about staffing levels, but there was no indication of this issue being considered and reviewed by management.

We saw there was a lack of regular engagement with people and their representatives. Although we saw some questionnaires had been filled in with some people and relatives’ feedback, with the support from staff, several people and relatives told us they had not been asked for feedback about the home. Their comments included, “They don’t ask me any questions. This is the first time I have been asked” and “I haven’t had anything like that.”

There was a whistleblowing policy in place and staff told us they knew how to use it.

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

We received mixed feedback from staff in relation to how much they enjoyed working at the home and how supported they felt in their job.

Staff consistently told us they did not receive supervisions on a regular basis. After our visit we reviewed evidence of supervisions taking place.

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.

We found the management and clinical oversight of essential areas of delivery of care was not always robust or effective. Governance systems in place had either not identified or addressed concerns found during this assessment. For example, people's weights were not being appropriately monitored to ensure concerns with weight loss were timely identified, monitored or actions taken.

Although there was a management structure in place at each unit, we found examples of lack of leadership and accountability in the running of the day to day of the service.

Quality assurance processes had not always been effective in driving the necessary improvements. We found examples where the issues found during our assessment were not previously known by the provider, even though quality checks were being completed in these areas such as medicine audits. We found several examples where issues identified by our assessment were known to the provider but appropriate action had not been taken in a timely manner. For example, issues with lack of timely referrals completed to healthcare professionals had already been identified during care planning and within the regional manager’s auditing.

In our previous inspection, the service was rated Requires Improvement and we identified breaches of regulations. At this assessment, the provider continued in breaches of regulations, and we identified further breaches.

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 several people required a referral to be completed to external health professionals for a review of their care but this had not been carried out. The management team had identified this was an issue but required action had not been taken until prompted by the assessment team.

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.

Opportunities for learning from accidents and incidents were missed. Some analysis of themes and patterns were completed by the provider but these were not acted upon when trends were identified to ensure people received safe care.

We identified several breaches of the relevant regulations, which indicated the provider had not sufficiently focused on and enabled continuous learning and improvement.