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 changed to requires improvement.

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 provider remained in breach of legal regulation in relation to governance and record keeping 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 and culture that was consistently understood and embedded across the service.

Staff described the manager as approachable and visible, and most people and relatives experienced positive interactions; however, at the time of our visit, more work was needed to ensure stable leadership in order to drive improvements forward and promote a positive, open and transparent culture where any issues were identified and addressed.

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; however, they were open and transparent during our inspection.

The service had experienced frequent changes in registered managers in recent years, which had resulted in unstable and inconsistent leadership. At the time of the assessment there was a new manager in post who had worked for the service for several years in a deputy capacity and was going through the process to become registered with CQC. The lack of ongoing consistent leadership had impacted on the quality and safety of the service.

Staff and people’s relatives spoke highly of the new manager and the improvements that were being made to the service; however, we identified concerns about the number of changes in management and the impact this had on consistency and ways of working within the home. Recent changes had not had time to fully embed and impact on the overall improving direction of the service.

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

Staff told us they felt comfortable raising concerns and would feel safe to whistle blow if needed. A staff member told us, “There is a number in the office we can call, and I would feel happy to raise concerns if necessary.”

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 service had a diverse workforce, and we found no evidence of any discrimination present. Staff told us the leadership team treated staff equally, there was an equality and diversity policy in place, and staff had completed equality, diversity and inclusion training.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Although there were some improvements identified at the time of our assessment, we were not assured there was robust and effective governance and oversight at the service because of inconsistency in management. The provider had a range of quality assurance systems and audits in place and although these were completed regularly, they had not always been effective in identifying some of the concerns found during this inspection, for example people’s care plans were not clear and easy to follow for all staff.

The manager was actively involved in all aspects of the service and was observed having a ‘hands on’ approach and open-door policy; however, because of very recent changes to the management structure, we were not fully assured all improvements were embedded and sustainable,

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.

Staff had worked hard to improve relationships with health professionals, working in collaboration with other services to ensure good, joined up care for people.

We saw positive feedback from other professionals and care records evidenced robust information sharing.

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

During our assessment, we identified weaknesses in the implementation of the governance and quality assurance systems within the service which meant there was limited scope for the service to learn and to continuously improve; however, the leadership team understood the importance of having a stable and consistent management and staff team in place to support ongoing service development.