CQC report explained · a residential care home
What the CQC found at 41 West Hill
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2024
Rated Inadequate and placed in special measures; inspectors found serious risks involving safeguarding, restraint, staffing and management.
The inspection took place on 25 and 26 October 2023, with an unannounced return on 6 November after further concerns were received. Inspectors observed care, spoke with a person, relatives, professionals and staff, and checked care, medicine, incident, staffing and management records.
The home was not safe. Staff did not always recognise or report possible abuse, risks from restraint were not properly reviewed, fire safety checks were incomplete, some water temperatures were too high and medicines were not always managed safely. Staffing and training did not always meet people's needs.
Care was rated Requires Improvement because people were not consistently involved in decisions, supported to communicate, or helped to follow their interests. The home was rated Inadequate for being safe and well-led. Inspectors found poor oversight, a closed culture and ineffective quality checks.
The overall rating is Inadequate and the home is in special measures. The provider must send an action plan, and CQC said it will monitor progress and normally re-inspect within six months unless it proposes cancelling the provider's registration.
Infection control
Inspectors were assured that infection prevention arrangements, including visitors, protective equipment and the home's infection control policy, were suitable.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Health referrals
The home made health referrals promptly when people were unwell, including contacting a GP when needed.
“The provider had made health referrals in a timely manner.” from the report
Safe recruitment
Inspectors found that recruitment procedures were safe.
“The provider operated safe recruitment processes.” from the report
Safeguarding failures
seriousStaff did not always recognise or report bruising, marks and other possible safeguarding incidents. This meant possible causes were not investigated and people could remain at risk of harm.
“Staff failed to recognise and report safeguarding incidents.” from the report
Unsafe restraint
seriousRecords did not show clearly that restraint was necessary, proportionate or used for the shortest time. The home did not consistently review restraint afterwards or look for ways to prevent it.
“People were at risk of harm by restrictive practice.” from the report
Fire and environmental risks
seriousFire alarm testing was not completed as required and fire doors were wedged open. Water temperatures exceeded safe levels without staff taking action.
“Fire doors had been wedged open.” from the report
Person-centred care
seriousPeople were not consistently supported to make choices, communicate, maintain privacy or follow hobbies and activities. Care was described as staff-led and task-focused rather than centred on each person.
“We found the service was staff and task-led, rather than person-centred” from the report
Poor management oversight
seriousThe provider's checks did not identify or fix repeated problems. Important incidents were not always reported, and relatives said information was not always open or shared properly.
“The provider failed to have an effective quality monitoring system to inform them of areas of the service that required improvement.” from the report
- 01What changes have you made to investigate safeguarding concerns, including bruising and marks, and how are these now reported?
- 02How do you record, review and reduce the use of physical or chemical restraint, and what checks confirm it is necessary and proportionate?
- 03How will you ensure there are enough suitably trained and deployed staff for one-to-one and two-to-one support, including community activities?
- 04How are you ensuring people can use their preferred communication methods, including Makaton?
- 05What independent checks now monitor incidents, medicines, fire safety, care plans and the quality of care, and can relatives see the results?
This was a focused inspection of Safe, Caring and Well-led; Effective and Responsive were not inspected and their previous ratings were used to calculate the overall rating. This explanation was written from the published report of 11 January 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2017
41 West Hill was rated Good; inspectors found safe, caring support, with some care records and planning still being developed.
This was an announced inspection on 14 November 2017. One inspector and an expert by experience visited. They spoke with people using the home, relatives, staff, the registered manager and company directors. They also checked care records, medicines records, staff files and management records.
The home was supporting three people and could accommodate up to five. Inspectors found enough staff, safe medicines management, clean surroundings and staff who understood people's risks and communication needs. People were supported to make choices, take part in activities and maintain contact with relatives.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. This was the first inspection since the home registered with CQC. Some records and monitoring systems were still being developed, but the registered manager had taken action on one records issue after the inspection.
Positive relationships
Staff were kind, warm and respectful. Inspectors saw people looking relaxed and comfortable with staff who understood their individual ways of communicating.
“We observed staff interactions with people and we saw staff were kind and caring to people when they were supporting them.” from the report
Support with behaviour
Staff had detailed guidance about triggers and positive responses. Relatives and staff reported that some people's behaviour had improved since moving to the home.
“There were extensive plans in place informing staff of how people's behaviour should be responded to in all aspects of daily living.” from the report
Safe medicines and staffing
Inspectors found medicines were given as prescribed and records and stock checks were correct. There were enough staff to provide support when people needed it.
“We found the medicines systems were organised and that people were receiving their medicines when they should.” from the report
Activities and community life
People were supported to follow their interests and go out regularly. Activities included music, art, football, horse riding, swimming and community trips.
“People were supported to follow their interests and take part in social activities.” from the report
Capacity decision records
needs fixingInspectors found that records did not always fully show the decisions made when a person lacked capacity. The registered manager took action after the inspection.
“There needed to be improvements in relation to the records kept of the decisions made If the person had been assessed as not having the capacity to make a decision.” from the report
End-of-life planning
needs fixingPeople's wishes about end-of-life care had not yet been assessed or recorded. The manager said this would be explored later where appropriate.
“People's wishes for when they reached the end of their life had not yet been assessed or planned for.” from the report
Diverse needs
needs fixingThe assessment of people's diverse needs, including needs linked to protected characteristics, was not yet fully embedded.
“The assessment of people's diverse needs to ensure there was no discrimination, including in relation to protected characteristics under the Equality Act was not yet embedded in the service.” from the report
Quality monitoring still developing
minorThe home had started some audits, but further checks and feedback systems were still being developed because the service was new.
“Systems were being developed to monitor and improve the quality of the service provided.” from the report
- 01How were the improvements to records of capacity decisions completed after the inspection, and can you show me an example?
- 02How do you now record and review each person's end-of-life wishes?
- 03How do you assess and record people's diverse needs, including needs linked to protected characteristics?
- 04What quality audits and feedback meetings are now in place, and what changes have they led to?
- 05How do you make sure each person receives one-to-one support and has enough staff when going out into the community?
This was an announced comprehensive inspection covering all five CQC questions and was the first inspection since the service registered. This explanation was written from the published report of 13 December 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of 41 West Hill
2 rated inspections over 6 years: the service has slipped, from Good to Inadequate.
- January 2024Inadequatecurrent ratingdown from GoodSafe: InadequateEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Inadequate
- December 2017GoodSafe: GoodCaring: GoodWell-led: Good
- March 2017
Registered with the Care Quality Commission on 6 March 2017.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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