West Cotes Residential 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 requires improvement. At this assessment the rating has remained 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 at the service.

This service scored 54 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

There was no clearly defined or consistently embedded shared vision or culture recognised by staff. This reduced assurance that staff were working within a consistent set of values and expectations, which may impact team cohesion and the consistency of care provided to people.

The service aimed to maintain a homely environment, supporting people to continue with familiar routines and activities. Positive examples of a caring culture were observed, including staff responding promptly to people’s needs, which supported their comfort and wellbeing.

Efforts had been made to promote engagement and communication, including the use of a newsletter to involve people in the service. There were also examples of staff working to build trusting relationships with people, which supported a more personalised approach to care.

While aspects of a caring culture were evident in practice, the lack of a clearly embedded and shared direction limited consistency across the service.

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, or they did not always do so with integrity, openness and honesty.

The registered manager was also the registered manager for another home. This meant they were only present in the home for one to two days per week, which limited consistent oversight of day-to-day operations. Responsibility for the service had largely been delegated to the deputy manager; however, they did not demonstrate the skills, knowledge, or experience required to effectively lead the service.

This lack of leadership capacity and oversight had resulted in shortfalls identified across other areas of this report, reducing assurance that risks were identified, monitored, and addressed in a timely way. In addition, there was limited evidence of proactive leadership, with repeated improvements required across previous inspections, indicating challenges in sustaining progress.

While the management team were responsive to external advice and guidance, there was limited understanding of what constituted good quality care in practice. This impacted the provider’s ability to drive continuous improvement and ensure consistent, high-quality outcomes for people.

The provider fostered a positive culture where people felt able to speak up.

Staff reported they felt able to raise concerns within the service. This supported a culture where staff could share information related to people’s safety and wellbeing.

However, there was reduced assurance that staff possessed the necessary knowledge and understanding to recognise and appropriately escalate concerns or emerging issues. Combined with wider concerns relating to oversight and leadership, this limited assurance that issues requiring improvement would be consistently identified and addressed.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff handovers took place before each shift and staff were expected to attend 15 minutes before their paid working hours commenced. As this time was unpaid, it did not promote an equitable approach to working practices, as staff were expected to contribute to care delivery activities before the start of their paid shift.

This had the potential to affect staff morale, engagement and inclusion, particularly for staff facing personal or financial challenges. As a result, there was reduced assurance that all staff were appropriately supported to participate fully in essential communication processes.

The registered manager demonstrated a flexible and person-centred approach to workforce management, supporting staff to meet their family commitments outside of work.

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.

There were ongoing gaps in governance systems, including auditing and monitoring processes, with repeated issues identified from previous inspections. This reduced assurance that effective systems were in place to identify, address, and sustain improvements.

Policies were in place; however, these were not consistently embedded into practice, impacting the consistency and quality of care provided to people. Monthly governance reporting was completed, although oversight was not always effective in driving improvement or ensuring identified actions were followed through.

There was a lack of role clarity between the registered manager and deputy manager, which impacted accountability and consistency in leadership. Audit responsibilities were dispersed across both roles, which limited oversight of key areas, including training, risk, and overall service improvement. This further reduced the provider’s ability to drive and sustain progress.

There was limited evidence of provider-level oversight within the service, with responsibility largely held by the registered manager. This reduced external challenge and independent review of service performance.

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.

Support was provided to enable people to access the community, including maintaining mobility equipment to promote independence and participation in activities outside the home. This supported people to remain connected and engaged with their local community.

The service worked in partnership with a range of external healthcare professionals to support people’s needs, with evidence of effective liaison and coordinated care. The management team were responsive to advice and guidance from outside agencies, which supported the delivery of care and access to additional expertise where required.

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.

Learning was not consistently embedded across the service. Issues identified during previous inspections, including gaps in governance and auditing systems, inconsistent training compliance, and weaknesses in leadership oversight had reoccurred. This reduced assurance that lessons had been effectively learned or that improvements had been sustained over time.

There was limited evidence of proactive review or forward planning by leadership. The registered manager was not always looking ahead to identify and plan for future risks, challenges, or changes in people's needs.

This impacted the provider’s ability to drive continuous improvement and respond effectively to emerging risks.