Westcliff Lodge Limited

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 inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. This meant the service 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 regulations in relation to their governance processes. The service was in breach of this regulation at the last assessment. This meant there was a continued breach of legal regulation.

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 service did not always demonstrate a clear shared vision, strategy and culture based on inclusion and engagement. It was not always clear how people were being empowered to take control or make decisions about their care. Leaders did not always promote a culture based on listening, learning and improvement. Training and development had not always been implemented effectively to ensure staff had the right skills and knowledge to deliver safe, high quality care. The service did not have a robust action plan in place to manage ongoing risks and there was no clear strategy to effectively address areas where improvements were needed.

Not all leaders understood the context in which the service 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. Leaders did not always use appropriate language when describing people’s care needs. This meant they were not consistently role modelling positive, respectful behaviours and values within the service.

The service fostered a culture where people felt they could speak up and their voice would be heard. Staff told us they were able to raise concerns with the management team. Staff knew how to access information about whistleblowing and speaking up if required.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. The service had policies in place to support fair and inclusive recruitment, induction and training for all staff. Staff told us they were able to request any additional support they required.

The service did not have clear 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. At our last inspection we found the service’s quality assurance processes had failed to identify concerns. At this assessment we found continued concerns with the service’s governance processes. Management audits and checks had not been implemented effectively. This meant they failed to identify and address concerns relating to people’s health and safety including the safe management of medicines, environmental risks and infection prevention and control. Leaders had failed to robustly monitor areas of concern identified at the last inspection to ensure improvements were made to the quality of people’s care. For example, people were still failing to receive person-centred care tailored to their individual needs and preferences. Leaders did not always demonstrate robust oversight over the management of accidents and incidents. Appropriate statutory notifications had not always been raised with CQC in line with the provider’s regulatory responsibilities.

The service understood their duty to collaborate and work in partnership with other health and social care professionals and local community groups to support people’s needs. We received positive feedback from the health professionals who worked regularly with the service. Comments included, “The service engages well with us”, “They are prompt to request support, and take our advice on-board” and “Communication has been excellent by the manager who has been responsive to my requests for information”.

The service did not focus on continuous learning, innovation and improvement. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. The service has been rated requires improvement in well led at their previous 4 inspections. At this assessment we found the service had failed to make and sustain the necessary improvements. During our assessment we identified a number of concerns which had been raised at previous inspection visits and found continued breaches of regulation. This demonstrated a poor culture of learning and a failure to drive improvement.