CQC report explained · a residential care home
What the CQC found at West Park Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that people were protected from abuse and avoidable harm, received medicines safely and had enough staff to support them. They noted that medication competencies were not routinely completed and that accident analysis could be expanded.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Requires improvement
- Management systems had improved and the home had an open culture, but quality monitoring was not fully embedded. Environmental checks did not always identify problems, communal areas were not included and refurbishment planning was needed.
What inspectors found, June 2021
Rated Good overall; inspectors found safe, kind care, but the home still needed to improve its quality checks and leadership systems.
This was an unannounced, focused inspection on 27 May 2021. Inspectors checked Safe and Well-led. They spoke with people, relatives and staff, and reviewed care, medicines, recruitment and management records.
The home was rated Good for Safe. People were protected from abuse and harm, medicines were given safely, staffing was sufficient and infection control arrangements were in place. Medicines records and risk information had improved since the previous inspection.
The home was rated Requires Improvement for Well-led. Quality monitoring had improved, but checks did not always identify environmental problems, and communal areas were not included. The overall rating improved from Requires Improvement to Good because earlier legal breaches had been addressed.
Safe medicines
People received their medicines as prescribed. Recording and stock control had improved since the previous inspection.
“People received their medicines as prescribed. There had been improvements in recording medicines and the use of codes when medicines were omitted.” from the report
Enough staff
Inspectors found enough staff to support people safely. People and relatives spoke positively about the staff team.
“There was enough staff to support people safely. People and their relatives spoke highly of the staff team.” from the report
Infection control
Inspectors were assured that the home had arrangements for preventing and managing infections, including COVID-19.
“We were assured that the provider's infection prevention and control policy was up to date.” from the report
Open culture
People and staff said they could speak to managers and make suggestions. The home had listened to suggestions about meals.
“All staff and people spoken with described a culture of openness, being able to speak to managers and being able to make suggestions.” from the report
Quality checks missed problems
needs fixingSome environmental checks had been marked as completed even though inspectors found issues. Communal areas were not included in the checks, and the quality assurance system needed a clearer link between checks and completed actions.
“There were some shortfalls in the documentation regarding the environment; these had been ticked as checked but issues were found during the inspection.” from the report
Medication competency checks
minorStaff who gave medicines had completed training, but their practical medication competencies were not routinely checked.
“Staff who administered medicines completed training, although medication competencies were not routinely completed.” from the report
Accident analysis
minorAccidents and incidents were recorded, but the home needed to improve its analysis of patterns and trends.
“However, analysis of accidents could be expanded to record patterns and trends.” from the report
- 01What specific environmental problems were found after the inspection, and have they now been fixed?
- 02How do you check communal areas, and how do you record actions through to completion?
- 03How often are staff assessed as competent to administer medicines?
- 04What changes have been made to analyse accidents and identify patterns or trends?
- 05What is the timetable for the planned redecoration and refurbishment?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 25 June 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.
What inspectors found, December 2019
Rated Requires Improvement; inspectors found kind, responsive care but unsafe medicines management and weak oversight of quality.
This was the home’s first inspection since the provider changed. It was an unannounced visit on 29 and 30 October 2019. Inspectors spoke with people, relatives and staff, and checked care, medicines, recruitment and management records.
People generally said staff were kind, respectful and available. Inspectors rated the home Good for effective, caring and responsive care. People’s health, food, drink, choices, privacy and activities were mostly supported well.
The main problems were medicines not always being given as prescribed and gaps in medicines records. Cleaning checks, staffing assessment, accident analysis and wider quality monitoring were also not strong enough. The home was rated Requires Improvement overall, and for Safe and Well-led.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors found that people’s privacy, dignity, independence and cultural needs were respected.
“People were well-treated, and their diverse needs were respected.” from the report
Choice and involvement
People were involved in care planning and reviews. Staff asked for consent and supported people to make choices about their daily routines and care.
“People had care plan reviews and 'resident's meetings', where they were supported to make suggestions and decisions about the care they received.” from the report
Food and healthcare
People had meal choices and their nutritional and hydration needs were monitored where necessary. Staff contacted healthcare professionals promptly when needed.
“People were supported to access a range of health care professionals in a timely way.” from the report
Staff training and support
Staff received induction, training and supervision. People and relatives said staff appeared to know what they were doing.
“Staff had access to induction, training and supervision meetings.” from the report
Medicines were not always given safely
seriousSome people did not receive medicines as prescribed. Missing or unclear records made it difficult to check what had happened, and at least one person experienced discomfort and anxiety.
“Some people had not received their medicines as prescribed.” from the report
Quality checks were not effective
seriousManagement checks did not identify problems with medicines, cleaning, records and the environment. The report says the provider breached the good governance regulation.
“The provider had not established robust systems and processes to effectively monitor the quality of the service and respond to shortfalls.” from the report
Cleaning and infection control needed closer oversight
needs fixingSome areas needed tidying and cleaning, and cleaning schedules were not checked properly by management. Inspectors recommended using a recognised audit tool.
“Cleaning and infection control was not effectively monitored.” from the report
Staffing levels needed further checking
needs fixingPeople and staff generally felt staffing was sufficient, but information received after the inspection suggested there might be too few staff in the mornings. Inspectors recommended using a dependency-based staffing tool.
“Following the inspection, someone reported more staff were needed in the mornings as staff were very busy.” from the report
- 01What changes have you made to ensure every medicine, including creams and 'when required' medicines, is given and recorded correctly?
- 02How do you now check cleaning and infection control work, and who reviews the results?
- 03How do you calculate the number and mix of staff needed in the mornings and when people’s needs change?
- 04What actions have you taken to make quality audits identify problems before they affect people?
- 05How do you analyse accidents, incidents and care records so that lessons are acted on?
This was an unannounced planned inspection covering all five CQC questions, including the premises and care, and it was the first inspection since the new provider registered; the previous Good rating was from 2017 under the former provider. This explanation was written from the published report of 12 December 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.
Every inspection of West Park Care Home
2 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- June 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2019Requires improvementSafe: Requires improvementWell-led: Requires improvement
- November 2018
Registered with the Care Quality Commission on 1 November 2018.
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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