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 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 remained 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 governance at the service.

This service scored 36 (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 this assessment continued to indicate the culture of the service was not centred around people’s needs and safe. The provider had a recovery plan in place at the time of our assessment, however there was no evidence of completion of the actions listed in the plan or how staff had been involved in delivering it. We continued to find several areas of concerns that had been previously identified at our last assessmentsuch as with quality assurance systems, management’s oversight, risks to people and lack of person-centered care. This shows the service’s continued failure to address known issues linked to the safety, quality and management at the service.

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

Despite a change in leadership there were continued issues with the effectiveness of management’s oversight , which placed people at ongoing risk of harm. For example, managers’ daily walkaround were in place but these had not identified issues we found with staff deployment, safety of people or environmental risks. This had a negative impact on the quality of care and safety of people.

New processes and procedures had been implemented by the new management team, but these had not been implemented long enough to evidence if these were effective and sustainable.

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

There were policies and procedures for staff to speak up and share concerns, and most feedback received indicated they feel confident doing so.

People and relatives also told us they could raise a complaint if they wanted to.

However, we continued to find limited engagement to gather feedback from people and relatives. Some relatives told us they did not receive enough notice to attend the last relatives meetings. A relative who was unable to attend told us, “I have never had emails about anything from them either. It would be good to get more information. I haven’t been sent any newsletters or documents asking for feedback.”

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 had an equality and diversity policy in place.

Most staff told us they enjoyed working at the home.

Most staff told us they had received supervision. We reviewed some sample supervisions confirming this was 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.

During our last assessment we found concerns about the safety and governance of the service, and enforcement action was taken. At this assessment, we continued to find serious issues with the lack of effective management and oversight at the service. The lack of consistency in management meant systems and processes did not operate consistently, known issues were not addressed and there was poor oversight of the delivery of care provided.

The quality assurance processes in place continued to not be effective in addressing the issues found, such as care plan audits, resident of the day or medication audits. Recovery plans were not robust and had not driven enough improvements in a timely way.

People and relatives commented on the inconsistency of management team, “Managers have come and gone, and consistency has gone with them. There has been a high turnover of staff;” and “I feel that half the issues they have in the home is because they don't have permanent managers to build consistency and parity across the units” and “Constant changes of manager.”

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

We received feedback from some professionals which indicated joined up working and communication needed to improve by the service. Comments included, “They [staff] do not always write down the plan[we agree on]and the communication between staff is quite poor. Several incidents of staff having not actioned previous plans from clinical reviews.” The lack of effective and consistent join up work with other professionals placed people at risk.

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,outcomeand quality of life for people. They did not actively contribute to safe, effective practice and research.

We found limited evidence that the service had learnt and made substantial improvements following our last assessment despite receiving warning notice issue. The nominated individual told us about the additional resources allocated to the service and the further plans to develop it, butat the time of our assessment, these resources had not been effective in achieving the improvements required.

The quality of the care received at the service had not improved enough to ensure people living at the service received care that was safe and centred around their needs and preferences.