Westley Court Care Home

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• 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

We identified an ongoing breach of regulation in relation to governance. At our last inspection we rated this key question requires improvement. The rating for this key question has remained requires improvement. Systems and processes in place to identify and assess environmental risks were not always effective in addressing concerns raised. Actions were not always taken to reduce or remove risks in a timely manner. Areas of the premises needed improvement. Some work had been completed since out last inspection and further work was planned. The registered manager had started to introduce a culture of learning to ensure improvements were made, however, this had not yet been fully embedded. Despite these concerns, we acknowledged some improvements had been made since our last inspection. Systems to communicate information relating to people’s care needs had been effectively implemented. Policies were in place and up to date. The registered manager promoted an open-door culture for people, their relatives and staff. Staff felt supported and able to speak up if they had any concerns.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff felt they were supported by the registered manager. One staff member told us, “She [the registered manager] has an open-door policy and makes time for you even when she’s busy”. However, some staff told us they had not had a regular one to one meeting to discuss their performance and development. The registered manager was aware of this and planning to take action to address the shortfall.

There had been some changes of senior management, since our last visit, the regional manager and quality manager had left, the provider was in the process of recruiting to these positions. Interim arrangements had been put in place to support the registered manager during this time. The registered manager had only recently been in post when we carried out our last inspection. We could see they had made improvements from our last visit. Audits were being completed more consistently and people’s health and support risks were being managed more effectively.

Staff told us they were aware of how to raise concerns. Posters on how to ‘speak up’ were prominently displayed throughout the service.

People and their relatives were invited to meetings with the manager; however, the registered manager told us the meetings were not very well attended and was keen to improve on this. Surveys were also given to people and their relatives to provide feedback. Feedback received was evaluated to develop a ‘You said we did’ plan. A whistleblowing policy was in place to guide staff on how to raise concerns and there were opportunities for them to share their views or concerns at staff meetings or in person with the registered manager.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager told us about some of the changes and improvements since our last inspection. Refurbishment work was ongoing, and quotes had been obtained to make further improvements within the service. The provider had introduced a new system for the registered manager to complete monthly reports on key events in the service to improve their oversight.

The provider had governance systems in place to monitor the quality and safety of the service. However, where concerns had been identified through external and the provider's own audits and checks, it was not always evident that actions had been taken. For example, a fire risk assessment was carried out by an external agency on 24 February 2022, actions had been identified, however the action plan had not been completed at the time to demonstrate compliance. The current registered manager had created an action plan covering some of the points raised in the fire risk assessment, but we were not assured all actions had been addressed. This placed people at increased risk. Some of the issues we found during our assessment had not been identified by the providers checks and audits. The registered manager was aware of the need to promptly inform CQC of any notifiable incidents in accordance with their legal responsibilities, however, following a review of information off site, we identified two occasions where notifications had not been submitted. The registered manager was made aware and took immediate action to submit the missing notifications. Staff were not always being supported with supervision meetings and appraisal of their performance. Despite our findings, we saw there had been improvements from our last inspection, regular auditing and checks were taking place and lessons learned from these and incidents that had occurred in the service. The registered manager was improving communication with people and their relatives by holding regular meetings and newsletters.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.