CQC report explained · a nursing home
What the CQC found at Westacre Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, April 2021
Westacre Nursing Home was rated Requires Improvement; inspectors found no evidence of harm, but risk management and oversight were not reliable enough.
This was an unannounced, focused inspection on 25 February 2021. Inspectors looked at Safe and Well-led because of concerns about safety and to check progress after the previous inspection. They spoke with people, relatives and staff, and reviewed care records, medicines records, staff files and management records.
The home was rated Requires Improvement for Safe and Well-led. Inspectors found no evidence that people were at risk of harm during this inspection, and saw kind and person-centred care. However, some nutritional risks were not managed or recorded well enough. There were also concerns about staffing deployment, agency staff induction and some mental capacity assessments.
The home had improved its medicines systems and infection control arrangements. However, its governance systems were still not effective enough to identify and correct problems across the service. This was the fourth consecutive inspection where the service was rated Requires Improvement or worse.
Medicines management
Electronic medicines records and daily checks had improved oversight and reduced medicines errors. Staff administering medicines had appropriate training and competency checks.
“Arrangements continued to be in place for the safe management of medicines.” from the report
Infection control
The home had procedures for visiting, testing, protective equipment and managing outbreaks. Inspectors were assured about several parts of its infection prevention arrangements.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Kind care
Inspectors observed staff supporting people gently and respectfully, including during transfers and meals. People and relatives generally described the care as person centred.
“Our observations during the inspection indicated that staff were kind, caring and attentive and provided care in a person-centred manner.” from the report
Learning from incidents
The home reviewed safety incidents and used them to identify possible improvements, such as extra checks or training.
“Safety related incidents were used as opportunities for learning and there was evidence that improvements were made in response such as additional checks or training.” from the report
Nutrition and choking risks
seriousSome nutrition plans and food and fluid records did not give enough assurance that people at nutritional risk received the right support. Two people were offered food that did not match their prescribed diets.
“Two people's food and fluid charts did not always provide assurances that, despite their nutritional risks, they had always been offered regular snacks and fluids to enhance their dietary intake.” from the report
Governance and records
seriousManagement systems did not consistently identify and correct problems. Some care records were incomplete or conflicting, legionella records were not reassuring, staff supervision was not embedded, and two incidents were not notified to the CQC.
“This was a continued breach of Regulation 17 of the Health and Social Care Act (Regulated activities) Regulations 2014.” from the report
Night staffing and agency induction
needs fixingThe home relied heavily on agency staff at night. Inspectors also found no records showing that agency staff had received an induction covering matters such as fire procedures.
“Every night between 8 February 2021 and 7 March 2021, three of the five required night care staff were agency workers.” from the report
Dignity and clothing
needs fixingTwo relatives reported that family members had sometimes been dressed in clothes that were not theirs and did not fit, affecting their dignity.
“Two relatives did express concerns about seeing their family members wearing clothes that were clearly not their own and which did not fit them, impacting on their dignity.” from the report
- 01How do you now check that nutrition plans reflect weight loss, choking and other dietary risks?
- 02How do you make sure food and fluid charts show that people receive regular snacks and drinks when they need them?
- 03What are the current staffing levels on day and night shifts, and how many agency staff are usually used?
- 04How are agency staff inducted, including training on fire procedures and people's individual needs?
- 05What action has been completed to address the continuing Regulation 17 breach, and how are you measuring progress?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from previous comprehensive inspections. This explanation was written from the published report of 9 April 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, August 2019
Requires Improvement; inspectors found kind and responsive care, but important safety records and quality checks were not reliable.
Inspectors visited without notice on 21 and 24 May 2019. They spoke with people, relatives and staff, and checked care records, medicines, accidents, complaints and quality checks.
People generally said they felt safe and happy. Staff were trained, medicines were managed safely, people could access health care, and care was usually personalised. The responsive rating was Good.
However, the computerised care records contained missing or inaccurate information about risks such as epilepsy, choking and diabetes. Recruitment checks were incomplete, hand-washing facilities were not adequate in two areas, and staff did not always treat people with enough consideration.
The overall rating was Requires Improvement, as were Safe, Effective, Caring and Well-led. This was the same overall rating as the previous inspection, and the home had been rated Requires Improvement or Inadequate at the last three inspections.
Safe medicines
Medicines were administered by staff whose competence had been checked. Records showed people received their medicines as prescribed.
“Medication administration records (MARs) confirmed that people had received their medicines as prescribed.” from the report
Staff training
Staff completed relevant training, received supervision and were supported with qualifications. New staff had an induction and shadowed experienced staff before working alone.
“New staff completed a comprehensive induction programme before being allowed to work on their own.” from the report
Personalised support
Staff generally knew people's routines, preferences and communication needs. People could choose when to get up, where to eat and how they wanted support.
“People's daily care records were up to date and confirmed that care and support had been delivered in line with people's needs, wishes and preferences.” from the report
Activities and end-of-life care
The home offered varied activities and had added evening activities. Staff had experience in end-of-life care and recorded people's wishes.
“People had access to a range of activities.” from the report
Supportive culture
The manager had worked to improve teamwork, communication and person-centred care. Staff said the atmosphere had become calmer and more organised.
“The registered manager had worked hard to develop a clear set of values and a positive culture within the staff team.” from the report
Inaccurate computer records
seriousInformation transferred from paper records to the computer system was incomplete or wrong. This included risks linked to epilepsy, choking and diabetes, and could have delayed safe care.
“The discrepancies between the paper records and the computer records had the potential to compromise people's safety.” from the report
Quality checks missed problems
seriousThe home's audits did not identify several issues found by inspectors, including inaccurate care records and missing hand-washing facilities. This was a breach of Regulation 17.
“The failure to operate effective systems to assess, monitor and improve the service was a breach of Regulation 17 of the Health and Social Care Act (Regulated activities) Regulations 2014.” from the report
Incomplete recruitment checks
needs fixingSome employment histories, references and health information had not been checked or recorded as required. The manager said procedures would be tightened and later provided information about steps taken.
“However, records showed the procedures were not always followed fully.” from the report
Post-fall checks
needs fixingStaff did not always follow best practice after head injuries. The report recommended a stronger protocol for neurological observations, including for people at increased risk of bleeding.
“We recommend the provider develops a robust head injury protocol in line with best practice guidance.” from the report
Choice and consideration
needs fixingAt times, staff did not explain actions or check whether people wanted clothing protectors, more food, a different drink or to be moved. This was particularly concerning for people who might not be able to ask for alternatives.
“People were not always treated with consideration and cared for or treated with dignity and respect.” from the report
Infection control facilities
needs fixingThere were no dedicated hand-washing facilities in the laundry or sluice room. Staff used sinks intended for other cleaning or kitchen tasks, creating a risk of cross infection.
“However, we identified that hand washing facilities were not available in the laundry or the sluice room.” from the report
- 01Have all paper care records been checked against the computer system, and how do staff know which information is current?
- 02What changes have been made to recruitment checks, including employment gaps, references and relevant health information?
- 03What written protocol is now used for neurological observations after a fall or head injury?
- 04Are dedicated hand-washing facilities now available in the laundry and sluice room?
- 05How do staff now offer food and drink choices to people who may have difficulty remembering or communicating their preferences?
This was a planned inspection based on the previous rating and covered all five key questions, including the care provided and the home environment. This explanation was written from the published report of 9 August 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 Westacre Nursing Home
5 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- April 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- August 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- June 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2018Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 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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