CQC report explained · a residential care home
What the CQC found at Dimensions 1-2 Westbury Way
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and managed, medicines were safely handled, staffing was suitable and safeguarding systems were clear. They noted that some PRN protocols and a liberty authorisation renewal were not updated in a timely way.
- Effective?
- Good
- This question was not assessed during this focused inspection. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This question was not assessed during this focused inspection. Inspectors observed kindness and compassion, but said their judgement on this aspect was limited by the inspection scope.
- Responsive?
- Good
- This question was not assessed during this focused inspection. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found that management systems had improved and that repairs and incidents were followed up more effectively. They recommended further work to ensure care records were reviewed and updated on time.
What inspectors found, October 2022
Rated Good after improvement; inspectors found safe care and stronger management, but some care records still needed timely updates.
This was an unannounced focused inspection on 13 and 14 September 2022. One inspector and one medicines inspector reviewed medicines, staffing, risks, repairs, infection control, care records and management checks. They also spoke with staff, relatives and a visiting professional.
The home was rated Good for Safe and Well-led. Inspectors found improvements since the previous inspection, including better handling of repairs, safer medicines systems, suitable staffing and clear safeguarding arrangements. Relatives and professionals gave positive feedback about the care and management.
Some records were not always reviewed and updated by their planned dates. This included PRN medicine protocols, risk plans and records of authorisations. Inspectors recommended that the home strengthen its checks. One working bath was available while repairs continued, with work expected in November 2022.
Safer medicines
Medicines were stored, given and checked safely. Staff were trained and assessed as competent before administering them.
“Medicines were safely managed. There were known systems for ordering, supporting, and administering and monitoring medicines.” from the report
Better repairs and risk management
The home had acted on earlier concerns about the building. Most identified repairs had been completed or were being followed up.
“At this inspection we found significant improvements had been made and to address these concerns.” from the report
Suitable staffing
Staffing levels were flexible and included extra support where people needed it. The home tried to use agency staff who knew the people and service.
“People had access to appropriate levels of staff to meet their needs.” from the report
Positive relationships and leadership
Relatives, staff and professionals described the management and care positively. Inspectors found that people were supported by staff who knew their needs well.
“We received positive feedback from relatives and professionals that the service was well-led.” from the report
Care records not always updated on time
needs fixingSome PRN protocols, risk plans and records of liberty authorisations were not reviewed by the planned dates. Inspectors recommended stronger management checks.
“However, we noted records relating to people's care were not always reviewed and updated in line with specified dates.” from the report
Limited bathing access during repairs
needs fixingPeople could access only one working bath because repairs were ongoing. The manager said work was planned for November 2022.
“However, we found people were still only able to access one working bath due to on-going repairs.” from the report
One delayed authorisation renewal
needs fixingInspectors found an example where an application to renew a person's legal authorisation had not been made promptly.
“However, we noted an example where an application to renew a person's authorisation had not been made in a timely manner.” from the report
- 01Have all PRN medicine protocols and risk management plans now been reviewed and updated by their planned dates?
- 02What checks are now in place to make sure legal authorisation renewal applications are submitted on time?
- 03Has the repair work been completed so people have access to more than one working bath?
- 04How are repairs and environmental risks recorded, escalated and followed up?
- 05What were the ratings for Effective, Caring and Responsive at the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other key-question ratings were carried forward from the last inspection. This explanation was written from the published report of 14 October 2022 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, March 2022
Requires Improvement; inspectors found serious property and governance problems, although care risks, staffing and medicines were generally managed.
The inspection visit took place on 15 February 2022. It was prompted partly by concerns about a recent COVID-19 outbreak. Inspectors looked at infection control and then widened the inspection to cover safety and leadership.
Inspectors found long-standing problems with the building. These included leaks, broken or missing fixtures, uneven floors, limited bathing and hand-washing facilities, and gaps in the fencing. These problems affected safety, quality of life and infection control.
The home had suitable risk assessments, trained staff and medicines processes. Relatives said people were safe and kept informed. However, repairs were not escalated effectively, some required notifications were not sent to CQC, and the home did not know about the correct cleaning products for a COVID-19 outbreak.
The overall rating changed from Good at the previous inspection to Requires Improvement. The provider acted quickly after the inspection and said most immediate repairs had been completed or arranged, but flooring still needed further investigation. CQC said it would continue to monitor the home.
Care risk management
People had risk assessments and staff understood the risks affecting individuals and how to manage them.
“Potential risks to people related to their care had been identified, assessed and managed.” from the report
Medicines
Medicines were given by trained staff, stored correctly and reviewed. Inspectors found processes for recording and learning from medicines incidents.
“People received their medicines safely from trained staff.” from the report
Staff recruitment
The home used recruitment checks, including DBS checks. Staffing gaps during the COVID-19 outbreak were covered by existing and agency staff, with no evidence that people's safety was compromised.
“The provider operated robust recruitment processes. Their staff pre-employment recruitment checks included a Disclosure and Barring Service (DBS) check” from the report
Open response
The provider acted quickly when inspectors explained the full extent of the problems and supplied an action plan and progress updates.
“They took swift action and immediately provided CQC with an action plan and updates.” from the report
Family communication
Relatives said they were kept informed about people's wellbeing and incidents.
“People's relatives told us they were kept updated and informed of any incidents, which records confirmed.” from the report
Unsafe building condition
seriousInspectors found a range of long-standing problems, including a leak through a fire alarm, broken fixtures, uneven floors and gaps in the fencing.
“We saw water leaking from the loft through the ceiling, directly through a fire alarm.” from the report
Infection-control risks
seriousLimited bathing and hand-washing facilities, laundry being taken through a kitchen and unlocked clinical waste bins increased infection risks. The manager was not aware of the correct cleaning products for a COVID-19 outbreak.
“The poor physical state of the environment and the lack of fully functioning bathing and hand washing facilities within each bungalow meant the risk of people and staff contracting an infection had increased.” from the report
Weak escalation of repairs
needs fixingMaintenance problems had been reported repeatedly, but the provider did not make sure the risks were escalated effectively to senior management.
“Effective actions were not taken to escalate the issues internally.” from the report
Missed notifications
seriousThe home failed to notify CQC about several incidents and the effect of property damage on care. The notifications were submitted after the inspection.
“The failure to inform CQC of notifiable incidents without delay was a breach of regulation 18” from the report
Medicine cabinet keys
minorKeys to two people's medicine cabinets were kept in their bedrooms, which could have allowed unauthorised access. Staff corrected this immediately when inspectors raised it.
“We found the keys to two people's medicine cabinets were stored in their bedrooms, which could have allowed unauthorised access.” from the report
- 01Which repairs identified in the report have now been completed, and what is the timetable for investigating and fixing the flooring?
- 02Are both bungalows now fully supplied with working baths, hand basins, toilets and suitable hand-washing facilities?
- 03What changes have been made to prevent laundry and clinical waste from creating infection-control risks?
- 04How are maintenance problems now escalated to senior management, and how is completion checked?
- 05How will the home make sure all future incidents and safeguarding matters are notified to CQC on time?
This was a focused inspection of Safe and Well-led, prompted partly by COVID-19 concerns; the other three question ratings carried over from the previous inspection. This explanation was written from the published report of 16 March 2022 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 Dimensions 1-2 Westbury Way
5 rated inspections over 7 years: the service has held its Good rating throughout.
- October 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- February 2018Goodstayed GoodSafe: GoodWell-led: Good
- June 2017Goodstayed GoodWell-led: Requires improvement
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- January 2012
Registered with the Care Quality Commission on 4 January 2012.
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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26 live-in carers within about an hour of Hampshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,260 a week. 23 can care for a couple. 14 years' experience on average.
“I cannot recommend Prisca highly enough, she is one in a million.”
“He stayed with her throughout the pandemic, refusing to visit his own family, who lived nearby, to reduce the risk of infection.”
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