Westerleigh

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 changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The provider had in place a range of processes to maintain the effective running of the services. Relatives and staff were positive about the registered manager and their oversight of the service. Relatives felt the registered manager was approachable. Regular checks and audits were undertaken, although these had not always highlighted some of the issues noted at this assessment. Professionals told us that communication with staff was variable, although was improving. The provider was committed to improving care and processes at the home.

This service scored 68 (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.

The provider had a clear vision of the culture and outcomes required for the home. People and professionals were optimistic about the registered manager and their positive impact on the service. Staff shared this vision and understanding of the need to provide high quality, personal and safe care. Comments from staff included, “It is so rewarding – I love the interaction. On this floor there are 2 ladies who like a cup of coffee first thing in a morning – so I sit with them. Just sitting and chatting when you have some time” and “I love it. If I didn’t, I wouldn’t be doing it. The best part is getting to know them – we are like their family. Especially when people don’t have family of their own. It is important to show compassion and kindness.”

People and relatives told us that all the staff at the home were kind, approachable, patient and understanding. Comments included, “I am fairly satisfied with how things are with my mum. Importantly – Mum seems calm, happy and smiles and laughs, which I think is a good indication of how things are” and “It’s brilliant, excellent, really can’t fault them. We have experienced other care homes, but this is so much better”

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.

People and relatives were positive about the registered manager and felt they had been a constructive influence on the service since they had come to the home. Comments from relatives include, “As a manager I have found [registered manager] to be excellent. Extremely efficient and communicative”; “[Registered manager] has made big steps and improvements since the home has come under her management”

Staff told us that the overall management of the service had improved in recent months and that they were now more positive about the home. They said that all managers who came to the service were approachable and would listen to concerns. They were particularly positive about the support they got from senior care workers, deputy managers and the registered manager. Comments included, “[Registered manager] is great. I get supervision off her. It’s been a while since we’ve had a good manager. She is firm but fair. If you have any personal issues you can go to her.”

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

People and relatives felt they were able to raise any issue or concerns. There were a range of avenues for doing this; they could speak to the registered manager, make a formal complaint or raise matters in resident and family meetings. One relative told us, “I go to the relatives’ meetings – the manager attends and will listen and take action where she can.”

Staff felt that the registered manager was approachable and listened to their concerns. Comments included, “[Registered manager] is nice – she has always been fair with me. I’m happy with how things are and wouldn’t hesitate to raise any issues."

The registered manager held a number of staff meetings and people told us they were able to raise issues in these meetings, if they felt it was important to do so.

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 were treated fairly by managers at the home and felt valued in their roles. The provider and registered manager valued diversity and ensured best practice guidelines were followed.

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 a range of checks and audits in place, but these had not always picked up on areas identified during the assessment. In particular, inconsistencies in care plan information and guidance had not been noted. Professionals were concerned about the continuing level of medicine errors at the home, despite input from various agencies to try and address the matter. Professionals also expressed concern about communication and felt that, whilst this was improving, there remained barriers to effective communication.

Staff meeting records indicated that staff were not always clear about their responsibilities and how they needed to respond to certain situations. Areas such as electronic records not always being completed, and the need to follow up actions, were noted. The registered manager was looking to address these issues and develop a more robust management system.

The registered manager undertook a range of audits for falls, weight monitoring and a number of other matters. Where concerns were noted, actions had been highlighted, such as referral to falls teams for people who fell frequently, or review by the GP for people who were losing weight.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Professionals told us the communication with the service had been an ongoing issue and remained a concern. They said this was slowly improving under the current registered manager, who they felt was making a positive impact at the home. Professionals also told us that some staff were not always up to date with key details about people who lived at the home, and that messages given personally to staff were not always passed to the next shift. One professional commented, “If communicating in person this is not always passed on. Carers can be inaccurate with histories – different stories from different staff members. Things have got better recently. [Senior carer name], one of the seniors is very good. They have a greater understanding of things.”

One relative also told us that information exchange was often difficult and that seniors on the floor did not always respond. They said, “The senior carers occasionally appear to be vague and unavailable. There have been several times I have requested information in relation to prevalent issues and have been met with assurances that enquiries will be made, and answers shall be forthcoming, but this has proven to be rarely the case.”

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.

The provider was committed to improving care at the home and developing new and innovative approaches to help improve people’s outcomes and maintain their wellbeing. Staff were enthusiastic about the improvements at the home and felt the current registered manager was a positive influence on the service and had raised the quality of care and improved the overall morale of the staff team. Staff told us they were being encouraged in self-development and were being offered opportunity for further training.

The registered manager told us they welcomed the CQC assessment visit as it helped them measure the recent improvements and judge what further work was required at the home.