CQC report explained · a nursing home
What the CQC found at West House Care Home Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found improved fire safety, safe medicines management, effective infection control and enough staff. Risks to people were identified and managed.
- Effective?
- Good
- This key question was not assessed during this focused inspection. Its rating carried over from the previous inspection.
- Caring?
- Good
- This key question was not assessed during this focused inspection. Its rating carried over from the previous inspection.
- Responsive?
- Good
- This key question was not assessed during this focused inspection. Its rating carried over from the previous inspection.
- Well-led?
- Good
- Inspectors found effective quality checks, required notifications to the CQC and a supportive management approach. Further improvements were planned.
What inspectors found, November 2022
Rated Good; inspectors found safer systems, kind care and better management after previous breaches.
This was an unannounced focused inspection. The inspector visited on 19 October 2022 and reviewed records, medicines, the building and management systems. They spoke with five people and eight staff.
The home was rated Good for Safe and Well-led. Inspectors found improved fire safety, safe medicines systems, effective infection prevention and enough staff. People were protected from abuse and harm, and risks were identified and managed.
The home had a warm and friendly atmosphere. Staff were described as kind and supportive. The provider had improved after the previous inspection, and the home was no longer in breach of regulations.
This inspection only assessed Safe and Well-led. The overall Good rating also used ratings from the previous inspection for the other areas, which were not reassessed.
Improved fire safety
A new fire risk assessment had been completed. Staff had fire safety training and fire drills were taking place regularly.
“A new fire risk assessment had been conducted, staff had completed fire safety training and fire drills were regularly carried out.” from the report
Safe medicines
People received their medicines as prescribed. Staff had training and regular checks of their competence.
“People received their medicines as prescribed.” from the report
Kind staff
Inspectors found staff kind and considerate when supporting people. The home was described as warm and friendly.
“The home had a warm friendly atmosphere. Staff were kind and considerate when supporting people.” from the report
Supportive management
Staff said they felt supported by the manager and provider. The manager was involved in the day-to-day running of the home.
“The registered manager had a hands-on approach. Staff told us they felt supported by the registered manager and provider.” from the report
Building work was unfinished
needs fixingThe provider was renovating the home, but its improvement plan was not complete because essential work had arisen. Ask what work remains and when it will finish.
“The registered manager explained that the provider's plan had not been fully completed due to unexpected essential work needed.” from the report
Care planning system needed extra paperwork
needs fixingNurses found that the electronic care plan system did not support effective risk assessments. They used additional documents to manage risks.
“Nurses had recognised the electronic care plan system did not support effective risk assessments and had produced additional supporting documentation to ensure risks were managed.” from the report
Further improvements planned
minorQuality checks were effective, but the manager believed more improvements were needed. A plan was in place to address them.
“The registered manager recognised further improvements could be made and a plan was in place to achieve this.” from the report
- 01What building and renovation work is still outstanding, and what is the expected completion date?
- 02How are risks recorded and reviewed while the electronic care plan system does not support effective risk assessments?
- 03What further improvements are included in the current quality assurance plan?
- 04How are medicines records kept accurate when the electronic system has internet problems?
- 05How will you monitor staffing levels if people's needs change?
This was a focused inspection of Safe and Well-led; the other ratings carried over from the previous inspection. This explanation was written from the published report of 16 November 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, May 2021
Rated Requires Improvement; inspectors found risks in care planning, fire safety and governance, although medicines were mostly managed safely.
This was a focused inspection because the agency had not notified CQC about some required events. Inspectors visited on 1, 6 and 13 April 2021. They spoke with people and relatives, staff and the manager, and reviewed care, medicine and quality records.
The home was not always safe. Some care plans did not reflect known risks. Fire safety systems were not always effective, some areas needed repair and redecoration, and medicine records had gaps. Inspectors found no evidence that anyone had been harmed, but said people were at risk because systems were not strong enough.
The home was rated Requires Improvement overall, and for Safe and Well-led. This was a focused inspection of those two areas only. The other ratings were carried forward from the previous comprehensive inspection, when the service was rated Good.
Infection control
Inspectors were assured that the home had arrangements to prevent and manage infection, including safe use of protective equipment and testing.
“We were assured that the provider was using PPE effectively and safely.” from the report
Staffing and recruitment
Staffing levels were monitored, and recruitment checks included background checks and references.
“The provider's recruitment process minimised the risk of unsuitable staff being employed.” from the report
Communication
People and relatives said communication was good and that they were kept updated about changes.
“We received feedback that communication with the service was good, and people and relatives were updated on any changes.” from the report
External relationships
The manager had built positive working relationships with external professionals.
“The manager had developed positive working relationships with a wide range of external professionals.” from the report
Care plans and known risks
seriousCare plans were not always in place or updated for known risks. Inspectors said this created a risk of harm, although they found no evidence that anyone had been harmed.
“Care plans were not always in place or updated in relation to known risks to people.” from the report
Fire safety and premises
seriousFire safety systems were not always effective, including fire extinguishers that had not been serviced as required. Some communal areas also needed repair and redecoration.
“Fire safety systems were not always effective. For example, fire extinguishers had not been serviced as required.” from the report
Medicine records
needs fixingMedicines were mostly administered safely and stored securely, but some administration records had gaps and there was no evidence that the reasons had been investigated.
“There were some gaps in medicine administration records with no evidence that action had been taken to investigate why.” from the report
Quality monitoring
seriousAudits had not identified or dealt with problems in care plans, the premises and required notifications. This was a breach of good governance.
“Quality assurance systems did not effectively assess, monitor and improve the quality and safety of the service.” from the report
- 01Have all care plans now been reviewed and updated to reflect each person's known risks?
- 02How do you now check that fire extinguishers and other fire safety systems are serviced on time?
- 03How are gaps in medicine administration records investigated and followed up?
- 04What changes have been made to the quality audits so they identify and correct problems?
- 05Have all required notifications to CQC been made correctly and on time since the inspection?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 15 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 West House Care Home Limited
5 rated inspections over 7 years: the service has held its Good rating throughout.
- November 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at West House Care Home Limited →
- May 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at West House Care Home Limited →
- July 2018Goodstayed GoodSafe: GoodWell-led: Good
- May 2017Goodstayed GoodResponsive: Requires improvement
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- February 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 13 January 2011.
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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