CQC report explained · a residential care home
What the CQC found at West Hall
Rated Outstanding: inspectors found the home performing exceptionally well.
- Safe?
- Good
- People felt safe, risks were assessed and staff responded to changes in people's needs. Inspectors found enough staff, good medicines management and clean, well-maintained surroundings.
- Effective?
- Good
- People's needs were assessed and care plans supported good outcomes. Staff had suitable training, people were supported with food and drink and healthcare, and the home followed the Mental Capacity Act principles.
- Caring?
- Outstanding
- Staff treated people with exceptional kindness, dignity and respect. People were involved in decisions and supported to remain independent and connected with others.
- Responsive?
- Outstanding
- Care was planned around each person's interests, wishes, health and social needs. Staff arranged creative activities, community links and highly individual end of life support.
- Well-led?
- Outstanding
- The registered manager had created a strong person-centred culture and used audits, meetings and feedback to improve the home. Staff were supported, given responsibility and encouraged to develop.
What inspectors found, June 2019
Rated Outstanding overall; inspectors found exceptionally caring, responsive and well-led care, while noting unwitnessed falls and a safeguarding investigation after the visit.
This was an unannounced routine inspection on 18 April 2019. Inspectors reviewed records, medicines, training, safety checks and surveys. They spoke with people living at the home, relatives, staff and health and social care professionals.
The home was rated Outstanding overall. Caring, Responsive and Well-led were Outstanding. Safe and Effective were Good. Inspectors found kind, person-centred care, enough staff, good medicines processes, clean surroundings and strong support for people's choices, activities and end of life care.
The report says the overall Outstanding rating from the previous inspection in 2016 was sustained. Safe and Effective stayed Good. Well-led improved from Good to Outstanding. After the inspection, CQC was told about unwitnessed falls and a complaint being investigated by the local authority safeguarding team.
Kind and individual care
Inspectors saw staff treating people as individuals and responding sensitively to their feelings, needs and choices.
“People were truly respected and valued as individuals; and empowered as partners in their care in an exceptional service.” from the report
Meaningful activities
Staff used people's life histories and interests to arrange personal activities, trips and opportunities for independence.
“Staff were flexible and responsive to people's individual needs and preferences, finding creative ways to enable people to live as full a life as possible.” from the report
End of life support
The home gave families flexible and compassionate support at the end of a person's life, including helping people achieve final wishes.
“Staff provided exceptional end of life care as they demonstrated distinctive skills in this aspect.” from the report
Strong leadership and improvement
The manager used regular meetings, audits and feedback to identify issues and make changes. Staff were encouraged to take responsibility.
“There was a strong emphasis on improvement.” from the report
Falls and safeguarding investigation
needs fixingAfter the inspection, CQC was told about several unwitnessed falls and a complaint being investigated by the local authority safeguarding team. The report says CQC was assured that full investigations and follow-up action would take place, but it planned to continue monitoring the home.
“Since our inspection, we have been made aware of a number of unwitnessed falls within the service and also a complaint which are currently being investigated by the local authority safeguarding team.” from the report
Previous medicines audit issue
minorAn audit in one lodge had found that medicines were stored together and medicine counts did not always match. The report says both problems had been addressed by the inspection.
“A medicines audit in one lodge identified that people's medicines were being stored together in a box, rather than each person having their own and medicines counts did not always tally.” from the report
- 01What happened in the unwitnessed falls mentioned after the inspection, and what changes were made as a result?
- 02What was the complaint being investigated by the local authority safeguarding team, and what was the outcome?
- 03How are medicines stored and counted in each lodge now?
- 04How would you support my relative's particular interests, independence and daily choices?
- 05How do you involve relatives in care reviews and decisions, especially if the person has dementia or cannot make a particular decision?
This was an unannounced routine inspection that looked at all five CQC questions and the overall quality and safety of the care home. This explanation was written from the published report of 26 June 2019 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, October 2016
Rated Outstanding; inspectors found exceptionally caring and responsive support, with a minor concern about following capacity decision-making procedures.
This was an unannounced inspection on 30 June 2016. Inspectors spoke with people living at the home, relatives, staff and health and social care professionals. They also observed care and checked care plans, staff files, training information, medicines records and other documents.
The home was rated Outstanding overall. Caring and Responsive were Outstanding. Safe, Effective and Well-led were Good. Inspectors found kind and respectful care, detailed care plans, meaningful activities, safe medicines practice, enough staff and strong management oversight.
There was one area to improve. In one case, it was not clear that the full legal process for checking capacity and making decisions had been followed. The provider was asked to roll out work to improve this.
Kind and respectful care
People and relatives spoke very highly of the staff. Inspectors saw staff taking time to understand people and treat them with dignity.
“People were extremely satisfied with the care they received and could not speak highly enough about the staff.” from the report
Personalised activities
The home offered activities and outings linked to people's past lives, interests and hobbies. Inspectors found these could improve confidence and quality of life.
“Activities were individualised, meaningful and well thought out with the focus being on people's past history, interests or hobbies.” from the report
Safe staffing and medicines
Inspectors found enough staff to meet people's needs and saw staff respond promptly. Medicines were ordered, stored, given and recorded safely.
“People received their medicines safely because staff had appropriate arrangements in place to order, store, administer and record medicines.” from the report
Detailed care planning
Care plans included people's preferences, health needs, communication and daily support. They were reviewed when needs changed.
“People's care plans were very detailed and written in a person-centred way.” from the report
Capacity and decision-making records
needs fixingIn one case, it was not clear that the full process for assessing capacity and making a decision had been followed. Inspectors recommended that the provider complete its planned improvement work promptly.
“However in this one case it was not clear that the full procedure for decision making and capacity had been fully followed.” from the report
- 01How do you assess a person's mental capacity for each important decision, and how do you record the decision-making process?
- 02What progress has been made with the work to improve compliance with the Mental Capacity Act?
- 03What was the outstanding complaint at the time of inspection, and has it now been resolved?
- 04How will you make sure activities continue to reflect my relative's past interests, hobbies and preferences?
- 05How are staffing levels reviewed when people's needs change?
This was an unannounced inspection covering all five CQC questions; the provider's information return was not available because the inspection took place sooner than planned. This explanation was written from the published report of 15 October 2016 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 West Hall
2 rated inspections over 3 years: the service has held its Outstanding rating throughout.
- June 2019Outstandingcurrent ratingstayed OutstandingSafe: GoodEffective: GoodCaring: OutstandingResponsive: OutstandingWell-led: Outstanding
- October 2016OutstandingSafe: GoodEffective: GoodCaring: OutstandingResponsive: OutstandingWell-led: Good
- April 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- July 2012
Registered with the Care Quality Commission on 3 July 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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