Westhope Lodge

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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

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 54 (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, the registered manager and the provider spoke of concerns around the lack of leadership and guidance from a previous senior leader. We were told this was now recognised by the provider and interim senior 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 registered manager. However, feedback about the management structure outside the immediate service was negative. One relative said, “They are not supported by Accomplish [registered manager and local team], it took months to get the lift replaced.” Staff told us they were supported by the registered manager. One staff member said, “The manager looks after staff.” Following our assessment visits the provider has demonstrated openness and honesty about actions they were taking to address shortfalls which included all staff receiving support from leaders.

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, leaving the registered manager and team with limited guidance and support. At the time of our assessment visit the provider had arranged for interim support to be available to the registered manager.

Staff felt able to share their concerns with the registered manager but until very recently they had not had very much contact with senior leaders.

Formal systems designed to gather feedback from people and staff had failed to be effectively used. For example, surveys of people, 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.

Staff told us they enjoyed working at Westhope lodge. One staff said, “I had a good induction, lots of shadowing other staff, and free to ask questions. I had help whenever I needed it. The manager is lovely, just had my appraisal all a really positive work environment.”

Processes in place had not effectively monitored the experiences of some staff. Staff felt able to talk openly to the registered manager. However, there were obstacles to staff or the registered manager speaking up to more senior leaders. Senior leaders had reviewed the service and put in place support for the registered manager and staff. However, this is very recent. Accomplish acquired the service in 2020 and effective quality assurance processes would reasonably have been expected to have picked up the culture among staff not being able to speak up and address accordingly.

Staff did not always have a clear understanding of their roles and responsibilities with incident and safeguarding reporting or medicine processes. A staff member had recorded a medical event on a form designed to identify trends of behaviour of concern. Some staff were not able to explain why risk assessments were in place or if they were the least restrictive option for people.

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 19 concerns which were identified during the CQC assessment visit. The providers own systems had failed to identify these or had recently identified but not acted upon them. The service had not completed an analysis of incidents which would have supported staff to understand what may have led to the persons distress and identified strategies and techniques to support the person. Audits had failed to identify people with a diagnosis of epilepsy did not have detailed plans and risk assessments about bathing or swimming. These activities are a known risk for anyone with the condition. At the time of the inspection the registered manager told us they were not aware of this risk. They immediately gained the information and created activity plans to share with the staff. The provider had not ensured managers and staff had this basic information.

People told us staff and the registered manager worked with health professionals and supported them with appointments.

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

Health professionals who gave feedback, expressed satisfaction with the engagement of staff and the registered manager in supporting people with their health needs.

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

Staff told us they had limited training around communication and sensory needs and limited knowledge of positive behaviour support (PBS) although the people living at Westhope Lodge had PBS plans in place. This increased the risk of people not receiving safe, effective care.

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 Westhope Lodge during this assessment visit. If learning had taken place appropriate protocols would have been in place. 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 training.