Westhope Place

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

There was a lack of effective oversight and governance to ensure people received care and treatment that met their assessed needs. There were widespread and significant shortfalls in peoples care which had not always been identified and when this had occurred there was insufficient action taken to ensure people received timely and appropriate support to meet their needs. Incident and accident reports were not completed or monitored to identify trends to improve the safety and quality of the service. Managers and staff had not always recognised and reported abuse and oversight systems and processes had failed to identify shortfalls in staff practice or consider risk mitigation measures. Care plans and risk assessments did not contain current contemporaneous information in respect to peoples changing needs.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were no local leaders available to provide feedback during this assessment. We have spoken to a number of senior leaders who were working at the service providing interim support. Staff provided feedback based on their previous experiences with local managers. Some staff told us they had not felt included or empowered to speak openly in the workplace. Generally, staff felt it had taken something awful to happen for people to listen. The provider in response to the identification of significant risks around the health and welfare of people had ensured a senior manager was available in the service to support staff and ensure people received support in accordance with their assessed needs.

The provider did not have effective systems that assessed or monitored the day-to-day culture of the service, and this meant they had not identified the significant concerns with the level of information available to staff regarding people’s needs and challenges.

Senior staff told us how Westhope Place linked with the organisation, “Accomplish acquired Westhope Ltd in 2020, integration took place, but it was during [the pandemic]. The area manager came from the previous provider”. There was evidence of significant shortfalls in the skills and knowledge of previous managers which had not been identified or managed by the provider. The director demonstrated their openness and integrity throughout our assessment and spoke of their focus on working with partners to ensure risks to people were managed and ensuring records were accurate.

The providers processes had not effectively measured the skills and competence of senior leaders and as a result had failed to ensure they received support to lead effectively. Subsequent to our assessment visits the provider identified incidents which had not been managed in accordance with their policies and processes and took action to notify CQC.

Some staff had shared concerns regarding how they had not felt able to speak up. Some staff told us they did not feel listened to when they had asked for clearer information about people’s needs.

Systems designed to gather feedback from people and staff had failed to identify significant concerns about the culture of the service where staff have not felt able to be open when things went wrong. For example, house meetings with people had not evidenced how the service was gathering feedback from people. Team meetings for staff did not provide assurance of an open positive culture in place. The provider had recently taken action to ensure improvements were made to support staff to have opportunities to talk through recent events and have their voices heard.

Whilst most staff told us they enjoyed working at Westhope Place some spoke clearly about recent challenges including the lack of effective leadership, lack of clear information about peoples needs and the death of a person following a choking incident. One staff member told us, “It’s not been easy but I can see potential here”.

Processes in place had not effectively monitored the experiences of some staff. Policies, procedures and quality assurance processes had not identified the significant shortfalls in the experience some staff received.

Staff did not have a clear understanding of their roles and responsibilities with incident and safeguarding reporting or medicine processes. Staff did not record incidents of self-injury or recognise the need to consider incidents within safeguarding policies or what action to take to mitigate risk. Managers failed to monitor staff practice which then resulted in a failure to investigate incidents resulting in some people being subject to potentially avoidable harm. For example, we checked staff understanding of reporting and one told us, “We use ABC forms”. Staff and managers were unable to provide evidence of any ABC records and as a result unable to evidence how people had been supported with behaviour reduction strategies. ABC forms are generally considered as a positive tool to assess the circumstances leading to a particular behaviour and help to identify strategies to reduce the instances of a behaviour. The provider was unable to provide assurance they had monitored staff performance or reduced the potential risk to people.

Oversight systems and processes had failed to identify shortfalls in staff practice or consider risk mitigation measures. Staff were not working in accordance with NICE medicines guidance. Medicine audits were not robust or contain adequate information and failed to effectively monitor medicines administration or provide assurance audits were regularly completed or include monitoring of staff practice. There were no clear protocols to advise staff when they should offer and administer service users their medicines that were prescribed on a PRN basis and this increased the risk that service users would not receive their medicines in accordance with prescribers’ guidelines. There was little or no evidence of learning from incidents, reflective practice or service improvement as a result people continued to be at risk of harm. At this assessment we found a significant number of breaches of regulations which the providers quality assurance processes had not identified

People were not always supported by staff who collaborated and worked in partnership with health professionals. For example as a result of a review of peoples choking risks health professionals had advised local managers about risks associated with supporting people with meals whilst in bed. Health professionals told us on their subsequent return visit the guidance had not been cascaded fully to the staff and as a result staff continued to place a person at risk of avoidable harm. The risks were raised by health partners and considered within safeguarding policy by the local authority.

Whilst staff told us people received regular input from community health professionals and people were supported to attend appointments there were shortfalls in communication with health professionals which resulted in continued risk of potential harm.

Health and social care professionals who had contact with Westhope Place expressed concerns with inconsistencies in information shared and shortfalls in some staff members knowledge. For example, one told us about recent enquires considering events around a person not being able to access some medicines. This highlighted shortfalls in managers and staff knowledge about medicines processes which potentially impacted on their ability to collaborate and work with partners to provide quality support to people.

Systems in operation had failed to gather feedback from visiting professionals or ensure the service was always working collaboratively. As a result, leaders increased the risk of missing opportunities for learning designed to improve the quality of support people received.

Staff spoke of training they had completed including moving and handling, medicines and how they supported people when they appeared distressed. Observations of staff and care records had evidenced shortfalls in their knowledge of good practice guidance about supporting people with a learning disability and Autistic people. This increased the potential risk of people not receiving safe, effective care.

The provider did not have quality monitoring systems in place to monitor staff practice that would have identified the need to ensure staff practice was in line with their training. The provider had failed to ensure staff had effective training to support people with complex needs including learning disability. People were highly dependent on staff knowledge and skills. Processes designed to be opportunities for staff to learn and be heard were not always effective. For example, a staff meeting had noted staff, “Not to argue with [people] you must treat them with respect”. This comment is indicative of staff who lack knowledge and skills with supporting people with a learning disability and Autistic people. The providers oversight processes had not identified or addressed concerns. This meant people continuing to be at risk of harm.