Whitwood House

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. Improvements were needed in relation to leadership of the service and quality assurance systems and processes. This meant there was a continued breach of legal regulation in relation to good governance.

This service scored 50 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

There was a shared vision and values in place at the service. During the assessment Staff demonstrated a positive and person-centred approach when supporting people. One staff member told us, “We go off the Lifeways values, the word choice is discussed at supervisions.” Staff also told us there had been an improvement in teamwork. Feedback included, “It wasn't easy when [the registered manager] came, it was difficult there were ups and down before [they] managed to bring everyone together and it’s better. [Staff] are working better as a team.” However, some staff felt improvements were needed regarding communication.

Leaders did not always have the necessary skills, knowledge and experience to lead effectively.

The registered manager had an inclusive approach and put people living at the service first. However, they did not always demonstrate the skills and knowledge to support effective management and leadership. For example, maintaining effective oversight and implementing effective audit processes. Provider level leadership had failed to effectively support sufficient development of the registered manager.

Concerns found during the assessment mostly related to quality assurance and oversight. Where concerns were highlighted with the registered manager during the process there was a lack of effective action.

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

Staff gave mixed feedback regarding whether they felt able to speak up and confidentially discuss concerns with managers. Feedback included, “Yes [I’m aware of freedom to speak up] but I don’t. My private information is everyone’s information, it’s everywhere,” “They try to listen to what you are saying” and “If I have any issues if I go to them, they are open and supportive. I feel it's an open place and I feel comfortable about raising any concerns I've got.” Improvements were needed to ensure all staff felt supported to speak up and that their concerns would be dealt with in confidence.

The provider valued diversity in their workforce. However, they did not always work towards an inclusive and fair culture by improving equality and equity for all people who worked for them.

The provider employed a diverse workforce from varying backgrounds and cultures. However, not all staff felt they were treated equally, and protected characteristics were not always effectively supported by management.

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.

The lack of adherence to clear roles and responsibilities within the management and leadership of the service meant appropriate delegation was not in place and quality assurance was lacking and ineffective. Quality assurance systems and processes were not always in place or effectively implemented to ensure safety and quality improvement. Matters identified through the assessment process had not been identified and/or addressed through the management team’s quality checks. For example, security of the premises, records and medicines; management of accidents and incidents; weight monitoring and record keeping. Where concerns were identified during the assessment process insufficient action was taken to act upon known risk. For example, the office door being left open. We identified a continued regulatory breach in relation to good governance.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. However, timely information sharing was not always in place.

A lack of oversight and robust monitoring at the service impacted the effectiveness of collaborative working and sharing of information. For example, during the assessment we found no incidents had been reviewed and added to the electronic system for a month. However, we found there had been occurrences that required incident reporting. This was raised with the registered manager who told us it was their responsibility to input the information onto the system and make the required notifications to CQC and the local authority if needed. Following our concerns the registered manager reviewed the incidents and found there were 8 incidents, 3 of which were notifiable to CQC. As these notifications were prompted by the inspection, we were not assured the information would have otherwise been shared as required.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

It was not clear how actions identified through quality checks, meetings and feedback were being logged, monitored and used to drive improvement. There was some evidence of lessons learnt being shared and actions arising from team meetings. However, there was no evidence to support how these were logged and tracked for compliance. In addition, staff told us they did not always get feedback from meetings or where lessons learnt had been identified there were delays in the information then being shared with them. The provider has been in breach of regulation relating to good governance for 3 consecutive assessments which demonstrates a failure to learn and sufficiently improve in this area.