CQC report explained · a nursing home
What the CQC found at The Westbourne Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments did not always cover all relevant risks, and staff did not always follow the guidance in place. The report also found some cleaning records were incomplete, although medicines were generally managed safely.
- Effective?
- Requires improvement
- Induction and training did not always prepare staff for their roles. Some food and fluid records were incomplete, and one person's DoLS conditions had not all been met.
- Caring?
- Good
- The report does not provide a Caring rating or a separate Caring findings section.
- Responsive?
- Requires improvement
- Care plans did not always contain enough personal information to guide staff, and some people's preferences and grooming needs were not fully met. Activities were available, but several people were not engaged in activities during the inspection.
- Well-led?
- Requires improvement
- Checks and audits did not identify all the problems found by inspectors. Records were not always complete or up to date, although managers were open about the shortfalls and were working on improvements.
What inspectors found, July 2023
The Westbourne Care Home is rated Requires Improvement; inspectors found risks, staff training and records were not always managed well.
This was an unannounced inspection after a complaint. Inspectors visited on 03 April, 06 April and 18 April 2023. They spoke with people, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
The home was fully staffed and people said they felt safe. Medicines were generally managed safely. Families could visit without restrictions, and staff worked with health and social care professionals.
However, inspectors found that staff did not always follow risk guidance. Some care records were incomplete or contradictory. New staff training and induction did not always give staff the knowledge they needed. The systems used to check quality and safety were not reliable enough.
The overall rating is Requires Improvement. Safe, Effective and Responsive were rated Requires Improvement. Well-led was also Requires Improvement, as it was at the previous inspection. The previous overall rating was Good, published on 26 May 2021.
Staffing
The home had recruited new staff and was fully staffed. Agency staff were no longer being used, supporting a more stable team.
“New staff had been recruited, which meant the home was fully staffed.” from the report
People felt safe
People inspectors spoke with said they felt safe. Staff understood their safeguarding responsibilities and knew how to report concerns.
“People spoken with told us they felt safe living at the home.” from the report
Family visits
There were no visiting restrictions, and relatives and friends were supported to maintain contact with people living in the home.
“Relatives and families were able to visit and supported to maintain relationships with their loved ones.” from the report
Risk guidance was not always followed
seriousInspectors found examples involving sensor mats, call bells, moving and handling equipment, and support during meals. These failures created an increased risk of harm.
“Where risks had been assessed, staff had not always followed the identified guidance to manage the risk safely.” from the report
Staff training and induction
seriousInduction records did not always show that training had been completed. Two recent incidents highlighted gaps in new staff's knowledge.
“We found the provider had not ensured staff had received appropriate support and training to carry out their roles effectively.” from the report
Care records
needs fixingSome records were incomplete, out of date or contradictory. This included information about nutrition and people's individual support needs.
“Records were not always complete and/or up to date with person centred information and some were contradictory.” from the report
Quality checks
seriousThe home's audits and improvement plan did not identify every problem found during the inspection. CQC found that governance systems were not robust enough.
“Systems to ensure compliance with the regulations, and systems to assess monitor and improve the service were either not robust enough or operated effectively.” from the report
Activities and personal support
needs fixingSeveral people stayed in their bedrooms without taking part in activities during the inspection. Inspectors also found that some grooming needs and personal preferences were not fully supported.
“During the inspection, several people remained in their bedrooms and were not engaged with any activities.” from the report
- 01What has been done to ensure staff always follow each person's risk assessment, including guidance about falls, call bells, sensor mats and moving equipment?
- 02How do you check that every new member of staff has completed induction and has the skills needed to support people living with dementia?
- 03Have all care plans been checked for missing or contradictory information, including nutritional needs and individual health conditions?
- 04How are you now checking that food and fluid charts, care reviews and other records are completed accurately and on time?
- 05What changes have been made to activities and one-to-one support for people who spend time in their bedrooms?
This was an unannounced inspection of the premises and care, including records, medicines, staffing, infection control and management systems; the report gives no separate Caring rating. This explanation was written from the published report of 22 July 2023 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, May 2021
The Westbourne Care Home is rated Good overall, but inspectors found that leadership and management systems still Require Improvement.
This was an unannounced focused inspection on 4 and 13 May 2021. Inspectors spoke with people, relatives, staff and a healthcare professional. They observed care and reviewed care plans, medicines records, staff files and management records.
The home had improved since the previous inspection in 2019. Inspectors found safe care, good support with eating and drinking, personalised care plans, activities and kind interactions. The home was clean and infection control arrangements were in place.
The overall rating was Good. Safe, Effective and Responsive were rated Good. Well-led remained Requires Improvement because the new manager was not yet registered, a deputy manager had not been appointed, some improvement actions were incomplete and records still had a small number of discrepancies.
Risk management
Risks were assessed and monitored more reliably than at the previous inspection. Records showed that pressure care and dehydration risks were being reviewed by senior staff.
“Records demonstrated these were now being monitored and reviewed by senior staff.” from the report
Medicines
A new electronic system had improved medicines management. Inspectors found administration records were comprehensive and medicines were given by trained staff.
“Records of administration were well maintained, in line with best practice and completed comprehensively.” from the report
Kind, personalised care
Care plans reflected people's preferences, and staff were observed providing positive interactions. People and relatives said staff knew people's likes and dislikes.
“Throughout our inspection we observed positive, caring interactions by staff who knew people well.” from the report
Activities and meals
Mealtime support and activities had improved. People had choices at meals, could eat at their own pace and could join activities such as exercise, music and crafts.
“Activity staff were motivated and encouraged people to engage in a wide range of activities within the home including physical exercise, music and crafts.” from the report
Leadership arrangements
needs fixingThe home had recently experienced several management changes. The new manager was not yet registered with the CQC, and a deputy manager had not been appointed.
“A new deputy was yet to be appointed and temporary arrangements were in place.” from the report
Improvements not fully embedded
needs fixingThe provider had made significant progress, but inspectors found that some actions were unfinished. A small number of care plan and record discrepancies needed to be addressed and checked consistently.
“Whilst significant progress had been made, some actions were not yet fully met.” from the report
Communication with relatives
minorSome relatives said communication had previously been poor and that they were not always told about management changes or given feedback from a satisfaction survey.
“Some relatives also told us communication had been poor prior to the new manager coming into post.” from the report
- 01Has the manager now registered with the CQC, and when will a deputy manager be appointed?
- 02How are you checking that the recent improvements to care plans and records remain in place?
- 03How will relatives be updated about management changes and the results of satisfaction surveys?
- 04How will our relative and family be involved in care plan reviews, especially if visiting arrangements change?
- 05How are agency staff use and night staffing being reduced while maintaining continuity of care?
This was a focused inspection of Safe, Effective, Responsive and Well-led; the Caring rating was not inspected separately and the report used previous ratings for key questions not covered. This explanation was written from the published report of 26 May 2021 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 The Westbourne Care Home
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- July 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2021Goodup from Requires improvementSafe: GoodEffective: GoodResponsive: GoodWell-led: Requires improvement
- December 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- March 2012
Registered with the Care Quality Commission on 9 March 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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