CQC report explained · a residential care home
What the CQC found at Westbourne Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- People generally felt safe, and medicines records and quantities matched. However, some risk information was not recorded in the most relevant care plans, some 'as needed' medicine plans were incomplete, and some staff did not wear masks correctly.
- Effective?
- Good
- People's needs were assessed and reviewed. Staff had training, people received suitable food and drink, and health professionals were involved when needed.
- Caring?
- Good
- People were treated kindly and with dignity, and were involved in choices about their care and daily routines. Inspectors asked the home to review how gender preferences for personal care were respected.
- Responsive?
- Good
- Care plans were detailed and person-centred. People had communication support, activities, opportunities to maintain relationships and support at the end of life.
- Well-led?
- Good
- People, relatives and staff were positive about the new manager and leadership. The home had systems for complaints, audits, learning from incidents and improvement planning, although these were still being developed.
What inspectors found, October 2022
Westbourne Care Home is rated Good overall, but inspectors found safety recording, medicines plans and mask wearing needed improvement.
Inspectors visited on 29 September 2022 without announcing the visit. They spoke with people, relatives, staff and health professionals. They reviewed care and medicines records, incidents, training and quality checks.
People generally said they felt safe and received kind, person-centred care. Inspectors found good support with food, healthcare, activities, communication and end of life care. Staff were described as friendly and knowledgeable.
The Safe rating was Requires Improvement. Risk information was not always recorded where staff would expect to find it, some 'as needed' medicines lacked full instructions, and some staff did not wear masks correctly. The carpets also needed cleaning or replacing.
The overall rating improved from Requires Improvement to Good. Effective, Caring and Responsive changed to Good, while Well-led remained Good. The manager was new in post and was developing further checks and improvement plans.
Kind and respectful care
People and relatives were positive about staff. Inspectors saw staff speaking kindly, asking permission and respecting people's choices.
“All interactions we heard and observed were positive.” from the report
Food and healthcare
People could choose their food, and the home monitored weight and provided fortified or modified diets when needed. Staff made referrals to health professionals and followed their advice.
“People were supported to eat and drink well and had access to health and social care professionals as needed.” from the report
Activities and relationships
People had access to events, outings, crafts and one-to-one activities. A wish list helped turn people's personal interests into planned actions.
“There had been a range of events, outings and crafts that people had enjoyed.” from the report
Open management
The manager responded to feedback, met relatives about concerns and introduced checks and action plans. Inspectors found improvements since earlier inspections.
“We found the manager to be open and responsive to feedback.” from the report
Risk information was not always easy to find
needs fixingSome instructions were recorded in one care plan but not in the section where staff would normally look. An incident had also not been reflected promptly in the care plan.
“More robust documenting of risk management was needed to ensure staff had clear information to follow.” from the report
Some medicine instructions were incomplete
needs fixingMedicine records and quantities matched, but some 'as needed' medicines did not have a completed plan explaining when they should be given.
“However, we also found that some 'as needed' medicines needed this plan to be completed.” from the report
Care preferences needed review
minorOne person said they preferred a staff member of a particular gender for personal care, but this preference had not been followed on the morning of the visit. The manager reviewed the arrangements afterwards.
“We discussed with the manager and asked that this was reviewed to ensure people were receiving care that was person centred and promoted their dignity.” from the report
Some premises cleaning was needed
minorInspectors said carpets in the lounges needed cleaning or replacing. They also questioned laundry being stored around a tumble dryer, and the manager later created a storage area away from the dryers.
“The carpets in the lounges needed to be cleaned or replaced.” from the report
- 01How do you now make sure repositioning instructions and other risk information are recorded in the care plan section staff use?
- 02Have all 'as needed' medicines been given clear written instructions about when they should be administered?
- 03What checks now make sure all staff wear face masks correctly?
- 04How will you record and respect each person's preference about the gender of staff providing personal care?
- 05What has been done to clean or replace the lounge carpets?
This began as a focused inspection of Safe and Well-led, then widened to a comprehensive inspection covering all five key questions; infection prevention and control was also checked under Safe. This explanation was written from the published report of 26 October 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, January 2022
Inspected but not rated; inspectors found people were generally safe and supported, but care records, fire drills and laundry arrangements needed attention.
This was an unannounced targeted inspection on 29 November 2021. Inspectors spoke with seven people, the manager, providers and six staff. They reviewed care and medicines records and took feedback from visiting professionals.
People said they felt safe and well supported. Inspectors found that risks were assessed, staff understood people's needs, medicines were managed safely and accidents were reviewed. Staff were described as kind and helpful, although some people sometimes had to wait for assistance.
The inspection did not give a new rating. The previous overall rating was Requires Improvement, published in April 2021. This visit only checked specific safety concerns, so the Safe rating remained 'Inspected but not rated' and a full assessment was planned for the next comprehensive inspection.
People felt safe
People told inspectors they felt safe and well supported. Staff knew about individual risks and how to reduce them.
“People told us they felt staff worked safely and looked after them well.” from the report
Medicines were managed safely
Staff had appropriate training, and checks and audits were carried out. The records inspected matched the medicines given.
“We checked a random sample of medicines and their medicines records and found they were accurate and administered as prescribed.” from the report
Accidents were reviewed
The home recorded accidents and incidents, followed up actions and looked for patterns that might help prevent them happening again.
“There was an analysis to look for themes or trends.” from the report
Care was being provided
On the inspection day, people's personal care needs were met. Inspectors found no increase in concerns linked to the reduction in night staffing.
“On the day of the visit we found people had their personal care needs met and records showed care was delivered regularly.” from the report
Care plans were not all up to date
needs fixingSome care plans did not accurately reflect current needs. This could make it harder for staff to follow the right care instructions.
“However, not all care plans had been updated to reflect current needs.” from the report
Fire drill was overdue
needs fixingThere had been no fire drill since June 2021, despite new staff and changes to night staffing. A drill was planned for the day after the inspection.
“However, there had not been a fire drill since June 2021, even though there had been new staff and a change to staffing levels at night.” from the report
Laundry room risks
needs fixingInspectors found items that could cause a fire and dirty washing on the floor, creating a possible cross-contamination risk. The manager said these issues were dealt with immediately.
“There was dirty washing all over the room, including the floor, risking cross contamination.” from the report
Occasional waits for help
minorSome people said staff were sometimes busy and they occasionally had to wait, including when they needed the toilet. Inspectors did not find that this happened often or affected care at the time.
“One person said, "It's hard sometimes when you need the toilet.” from the report
Vaccination status issue
needs fixingAn unvaccinated staff member worked two shifts after vaccination rules came into force before an exemption certificate was confirmed. The person was then removed from the rota.
“The manager told us, and the rota showed, that an unvaccinated staff member had worked two shifts since the regulations stated staff must be vaccinated to work in a care setting.” from the report
- 01Have all care plans now been updated so they accurately reflect each person's current needs?
- 02When was the planned fire drill completed, and how do you check that new and night staff know what to do?
- 03What changes have been made to keep the laundry room clean and free from fire hazards?
- 04Why was night staffing reduced from three people to two, and how do you reassess this if residents' needs increase?
- 05What checks are now in place to make sure all staff meet Covid-19 vaccination or exemption requirements?
This was a targeted inspection of specific safety concerns and infection control; it did not assess all five key questions or provide a new rating, so the previous Requires Improvement rating remained in place. This explanation was written from the published report of 12 January 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.
Every inspection of Westbourne Care Home
5 rated inspections over 7 years: the service has held its Good rating throughout.
- October 2022Goodcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2022Inspected but not ratedSafe: Inspected but not rated
- April 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Good
- March 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2017Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 7 December 2010.
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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