Westhope Mews

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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 found 1 breach of the legal regulation of governance. Risks to people were not adequately identified or managed. Staff did not always support people with medicines safely. There was a lack of effective oversight and governance to ensure people received care and treatment which met their assessed needs. Oversight systems and processes had failed to identify shortfalls in staff practice or consider risk mitigation measures.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Some staff, and managers spoke of concerns around the lack of leadership and guidance from a previous senior leaders. We were told this was now recognised by the provider and interim senior and local manager support had been put in place since spring 2024.

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 warning signs of a closed culture prior to an audit in March 2024 following significant concerns found at another local service.

Staff, relatives, and people provided positive feedback about the interim management team. However, the changes were recent and temporary. We found although local managers acted with integrity, they lacked knowledge in some areas of support practice. For example, risk assessment around eating and drinking, environmental risks and understanding their roles with MCA were all areas for improvement.

The providers processes had not effectively measured the skills and competence of leaders and as a result had failed to ensure they received support to lead effectively, team with limited guidance and support. At the time of our assessment visit the interim support to had begun to improve the support to the staff.

Staff felt able to share their concerns with the interim manager but until very recently they had not had very much contact with senior leaders. Staff told us, things had recently started to improve. One staff said, “Moral is getting better.” Managers told us there had been a recent turnover of staff and a core team was being developed.

The regional manager confirmed formal systems designed to gather feedback from relatives and staff had failed to be effectively used. For example, surveys of staff and relatives were not carried out. This was a missed opportunity to hear from relatives and staff which may have identified issues with the previous senior management of the service. People and staff meeting were being held.

Staff told us they felt working at Westhope Mews was improving. One staff said, “The managers support diversity.”

Processes in place had not effectively monitored the experiences of some staff. Staff now felt able to talk openly to the interim manager. Senior leaders had reviewed the service following issues raised from reviews of other services in the area and put in place support for the interim manager and staff. However, this is very recent and is not fully developed. Accomplish acquired the service in 2020 and effective quality assurance processes would reasonably have been expected to have picked up the cultural issues and address them.

Staff did not always have a clear understanding of their roles and responsibilities with understanding safety risks, particularly in relation to safe eating and drinking and some health conditions. Managers and staff were unclear how to motivate people to want to get up and participate in their daily lives, which in some cases led to people being unsafe. Staff and managers were not always able to differentiate between where a person had capacity to make decisions about particular areas of their life and where a mental capacity assessment was required, again leading to a lack of action and increased risk. Some staff were not able to explain why some practices were in place. A manager told us, they felt staff did not encourage people to leave their bed or rooms very much because they were worried people would respond with a behaviour of concern and hurt themselves or others. This culture had not been explored prior our assessment visits. This had not featured in any audit carried out by the provider.

Governance processes were not always effective and did not always keep people safe, protect their human rights and provide good quality care and support. The providers quality audit from May 2024 had identified shortfalls with lack of SaLT guidance, however had not appreciated the risk and not acted quickly to mitigate the risk. The providers own systems had failed to identify these or had recently identified but not effectively acted upon them. Audits had failed to identify people with a significant health diagnosis did not have detailed plans and risk assessments about managing the risks associated with the condition. The provider had not ensured managers and staff had the knowledge to identify the scale of risks in order to prioritise action.

People told us staff and managers worked with health professionals and supported them with appointments. We saw records of health appointments and referrals taking place. 2 people spoken with had a clear understanding of their current health conditions and the treatment they received. It was unclear if this was as a result of the staff support or family support.

Staff told us people received regular health care and they were able to explain how they raised health concerns and acted upon them.

Health & social care professionals who gave mixed feedback, Comments included, “One concern I had was that the client was still in bed at 11am and had not been up for toileting, showering or dressing by this time.” Another concern was about a person assessed as needing a special diet to reduce the risk of choking. However, the staff member supporting the person appeared to be unaware of this. Other professionals, when discussing a recent visit which followed our assessment visit, told us, “We observed positive interactions with residents and one resident gave positive feedback about the Peripatetic Manager.” And “No concerns were raised as a result of the visit and we did not identify any required actions.”

Systems were in place to record health appointments and actions required.

Staff told us they had limited training around communication and active support and limited knowledge of positive behaviour support (PBS) although the people living at Westhope Mews had PBS plans in place. Staff demonstrated little understanding of signs of people potentially having difficulty with eating and drinking, for example coughing while eating and drinking. These were significant concerns found in other of the providers local services in spring 2024 and had not been followed through into Westhope Mews at the time of our assessment visit. This increased the risk of people not receiving safe, effective care. The interim manager had been following up actions from previous audits and progress had been made in a number of areas.

Opportunities to learn from concerns raised at the providers other local services were missed. For example, Protocols for as required medicine (PRN) were improved following an assessment visit at another local service. The same concern about PRN protocols were found at Westhorpe mews during this assessment visit. Lessons had not been learnt around people eating in bed, which had been found at another local service. These had not been transferred putting people at risk of harm. If learning had taken place appropriate actions and protocols would have been in place. Went the issues were raised during this assessment with the managers at Westhope Mews they addressed them . The provider did not have effective quality monitoring systems in place to monitor staff practice that would have identified the need to ensure staff practice was in line with their policy and training. For example, Staff were not following the principles of active support training or MCA.