Westgate Court

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 good. 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 service was in breach of legal regulation in relation to governance.

This service scored 57 (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. The staff team were passionate about a shared culture of promoting independence and the registered manager and deputy manager had worked hard to instil a culture of openness and honesty. However, the shared direction and vision across the services was affected by the increasing pressure on team leaders and managers. As team leaders took on more responsibly to fill gaps in governance, roles and responsibilities blurred, there was a disconnect between the services who had varied approaches to policy and process. Due to this, the services were not always working in line with the providers own policies.

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. However, due to the issues identified during the inspection we could not be assured that leaders had the capability to lead effectively. Staff told us they felt unsupported in certain aspects of their roles, and they did not have the time needed with managers to ensure the service was well led. The registered manager and the deputy manager agreed that their time was limited and their capability to provide effective oversight in the service had been compromised by increasing workloads.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us the registered manager lead with an open-door policy and was approachable. Staff had the opportunity to discuss people’s care within daily meetings and handovers. Senior team meetings were also held to ensure staff could have their say.

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. There was an inclusive and fair culture with equality and equity for staff. Staff felt they were treated with respect and told us Westgate Court was a good place to work. One staff member said, “I love it here, I get really satisfaction from the job and it’s a great company.”

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 that not all areas of the service had effective checks taking place, which meant information about people’s care needs were not reflected or recorded in the care plans. For example, checks were not taking place on safety equipment, a system was not in place to review this safety need. People’s risk assessments did not accurately reflect the mitigation in place and risk assessments were missing for other high-risk areas such as falls. The providers governance system had not identified this.

Audits were taking place by the registered manager and the provider. However, these processes were not effective in identifying the concerns found during the inspection. For instance, internal checks failed to detect when people were missing mental capacity assessments. They also did not highlight when staff were not working in line with the providers over policies or when best practice was not in place. Managers failed to provide effective oversight within the services and inconsistently reviewed practice for safety and quality. Due to these concerns a breach of regulation was identified.

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 built a good relationship with local community teams and GPs to help support the service. Appropriate referrals were made to local authorities for support, where needed.

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. However, the provider had made investments into the service to help improve. For example, they had recently implemented a new electronic record system.

The provider had failed to ensure effective oversight of the service, audits had failed to highlight concerns that were raised during the inspection which impaired the providers ability to learn, innovate and improve. The provider was accepting of the feedback provided during the inspection and had started to reflect and plan improvement. However, more time is needed to embed good practice, improve and to show learning within the service.