Westmead

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 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.

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 had a shared vision, strategy and culture but work was still ongoing to implement this fully. The management team told us that since our last assessment, several processes and procedures had been changed at the home to ensure staff’s values and attitudes, as well as the processes in place supported a positive service culture and invited staff engagement.

Staff spoke positively about the impact and changes the registered manager had implemented. We reviewed the results of the last staff survey and we found mixed feedback. The service’s management team told us they were still working on an action plan for these results which would be shared with staff at the next team meeting.

Most relatives also shared positive feedback about the changes implemented at the service since our last assessment and the impact this was having on the culture at the service. A relative told us, "The shared vision we have got now, which is fantastic, and it's just because the leadership's changed. If the leader has the vision, the leader can take people there. What we had before was very different in comparison to now. [Person] has always had some very good strong bonds and relationships with some of the staff and it's never been an issue."

The provider had 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 had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager had made several improvements to the running of the service. People, staff and professionals were complimentary about them. Comments from a healthcare professional included, "I have been impressed with how much the registered manager and staff know about the service user, being able to have consistent staff that work with each individual is reassuring for the service user and for myself that I know that information they feed back is accurate.” A relative told us, “It is early days, [name of registered manager] has not been there very long, but from what I can understand, their enthusiastic, diligent, let's give them the chance. I'm fully supporting them at this moment in time because I think they are good for the service. [Name of registered manager] is obviously a caring individual. Because if they ring me, on a Saturday or a Sunday or whenever, they are bothered about [person’s] care, which is great.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Processes were in place for staff and people to speak up. The provider had a whistle blowing policy in place. Staff could raise concerns, and written information was available in staffs room and communal areas on how to do this. Staff meetings took place, and staff had the opportunity to share comments and give feedback after the meetings using an online form. Staff said they had confidence in the management team and would not be afraid of raising any concerns.

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.

Staff told us they enjoyed their place of work. The provider was proactive at engaging with staff and celebrating success.

At our last assessment, we found widespread concerns about the safety and management of the service. At this assessment, we found improvements in those areas and saw evidence of ongoing work being done to ensure these improvements continued to be embedded in the delivery of care. We found some issues during this inspection, which were mostly known to the provider, such as appraisals not always being completed in time or the way some staff spoke about people. The provider had a plan in place to address those issues. There was a system of regular audits in place including care records, medication, financial records, accidents and incidents. When issues were identified, these were acted upon in a timely way.

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.

Partners and healthcare professionals told us the service worked well with them to meet the needs of people. People were involved in regular activities that improved their engagement within the community and independence.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

There was evidence that learning from incidents and quality assurance issues identified were being used to improve the service provided. Patterns and trends were analysed on a monthly basis by the management team, and actions required were listed and acted upon.