CQC report explained · a nursing home
What the CQC found at Westbourne Tower Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found safe recruitment, enough staff, safe medicines systems and good infection prevention arrangements.
- Effective?
- Good
- People received support from trained staff and were helped to eat, drink and access healthcare. Inspectors identified that some areas were not dementia-friendly, assessments did not always fully explore protected characteristics, and mental capacity paperwork was not always consistent.
- Caring?
- Good
- People said staff were kind, respectful and helpful. Staff supported people to make choices and promoted their dignity, privacy and independence.
- Responsive?
- Good
- There was a broad activities programme and people were supported to maintain relationships and raise complaints. Care plans were not always detailed, and one person's communication needs were not initially fully supported, although the home acted quickly when this was identified.
- Well-led?
- Good
- People, relatives and staff spoke positively about the management team. Quality checks and learning systems were in place, although managers could not always be certain that all improvement actions had been completed.
What inspectors found, February 2023
Signature at Westbourne was rated Good; inspectors found kind, safe care, but identified gaps in dementia-friendly design, care records and some assessments.
This was an unannounced inspection on 30 January and 1 February 2023. Inspectors spoke with people living in the home, relatives, staff and health professionals. They observed care and checked care records, medicine records, staff recruitment files and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and were happy. Inspectors found that staff were kind and respectful, medicines were managed safely, people could access healthcare, and there was a wide range of activities.
Inspectors found some areas needing improvement. Parts of the building were not fully dementia-friendly. Protected characteristics were not always explored fully in assessments. Care plans were not always detailed, and mental capacity records were not always consistent. The home had started introducing a new electronic care planning system to address some of these issues.
The inspection also found that one person's communication needs had not been fully supported. The home acted quickly during the inspection by arranging support in the person's own language and updating the care plan. This was the first inspection of this newly registered service.
People felt safe
People told inspectors they felt safe and staff understood how to recognise and report abuse. Risks were discussed regularly and incidents were reviewed for learning.
“People told us they felt safe living at Signature at Westbourne.” from the report
Kind and respectful staff
People and relatives described staff as kind, respectful and supportive. Staff helped people keep their dignity and make choices about their care.
“People told us staff had taken the time to build trusting relationships with them and their families.” from the report
Safe medicines
Staff were trained and checked as competent to give medicines. Records were clear and complete, and medicines were stored and handled safely.
“Medicines administration records were clear, accurate and complete.” from the report
Good activities and relationships
People could choose from activities such as clubs, quizzes, games and outings. Families and friends were encouraged to visit and join activities.
“Signature at Westbourne had a range of activities on offer for people to choose from” from the report
Quick response to communication concern
When inspectors identified that one person was not being fully supported to communicate, the home arranged help in the person's own language by the next day and updated the care plan.
“This resulted in the person having an in-depth conversation about their life, their needs and wants.” from the report
Dementia-friendly environment
minorThe decoration and layout on the second and third floors did not always help people living with dementia understand where they were. Refurbishment plans were in place.
“The design and decoration of the premises did not always follow the best practice guidance for supporting people living with dementia.” from the report
Assessments did not cover all needs
needs fixingAssessments did not always fully consider protected characteristics, such as race, nationality or ethnicity. The home said a new electronic system would capture this information more robustly.
“Peoples protected characteristics had not always been considered as fully as they could have been.” from the report
Mental capacity records
needs fixingMental capacity paperwork was not always consistent. The home said care plans would be reviewed as people moved to a new electronic system.
“We found the MCA paperwork was not always consistent.” from the report
Care plans lacked detail
needs fixingSome care plans did not give staff enough detail to make sure people's needs were always met. A new electronic care planning system was due to be introduced.
“Care plans were not always detailed, and person centred.” from the report
- 01What refurbishment has been completed on the second and third floors to make the environment more suitable for people living with dementia?
- 02How do you now record and review each person's race, nationality, ethnicity, religion, relationships and other protected characteristics?
- 03Has the new electronic care planning system been introduced, and how do you check that care plans contain enough detail?
- 04How do you check that mental capacity assessments and related records are complete and consistent?
- 05How do you make sure every action from audits and quality checks is completed within an agreed timescale?
This was an unannounced first inspection of the newly registered home and covered all five key questions, including infection prevention and control under Safe. This explanation was written from the published report of 22 February 2023 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, February 2019
Sunrise of Westbourne was rated Outstanding overall; inspectors found exceptionally caring, personalised care, with safe and effective arrangements.
This was a routine, comprehensive inspection. It took place on 19, 21 and 27 November 2018, with the first day unannounced. Inspectors spoke with 20 people living at the home, 18 staff members and nine visitors. They reviewed care plans, medicine records, staff files, audits and maintenance records.
The home was rated Good for Safe and Effective. Inspectors found that risks were assessed, medicines were generally managed safely, staff were trained, and people had access to food, drink and healthcare. There were sufficient staff with the right skills, and the building was clean and well maintained.
The home was rated Outstanding for Caring, Responsive and Well-led. Inspectors found kind and respectful care, strong knowledge of people's lives and preferences, meaningful activities, support to stay connected with the community, and leaders who used feedback to improve the service.
The overall rating of Outstanding means the inspection found care that was consistently much better than the standard CQC normally expects. The report also noted that refurbishment work was taking place during the inspection.
Kind and personal care
Staff knew people well and supported them in a respectful way. Inspectors saw staff taking time to chat, promote independence and understand what mattered to each person.
“People, relatives and visitors all felt that the staff provided exceptional support.” from the report
Meaningful activities
Activities reflected people's interests, histories and abilities. The home also offered one-to-one support for people who were at risk of loneliness or preferred to stay in their rooms.
“There was a very strong emphasis on the provision of activities that were meaningful to the people living in the home.” from the report
Strong leadership
People, relatives and staff were confident in the management. Leaders sought feedback, acted on concerns and looked for new ways to improve people's quality of life.
“There was a very strong emphasis on continually striving to improve the service.” from the report
Good staff support
Staff completed induction and received regular training and supervision. Inspectors found staff had the skills and knowledge needed to meet people's needs.
“Staff were well trained and had the skills to meet people's needs.” from the report
Occasional medicine recording shortfalls
needs fixingMedicine systems were judged safe overall, but records and audits had found occasional shortfalls. The report says immediate action was taken when these were identified.
“Records and audits showed that these systems had identified occasional short falls and immediate action had been taken.” from the report
Some meals could be slow
minorOne person said there could sometimes be a long wait before food was served because there were many tables. This was an isolated comment in an otherwise positive account of meals.
“Yes, sometimes dinner is a bit slow, we sit down for a long time before getting served but there are a lot of tables.” from the report
Refurbishment was ongoing
minorMajor refurbishment was taking place during the inspection. People were involved in planning and updates, but families should ask about any remaining work or disruption.
“At the time of the inspection the home was undergoing a major refurbishment.” from the report
- 01What medicine recording shortfalls have occurred since the inspection, and what checks are now in place to prevent them?
- 02Has the refurbishment been completed, and are any areas still affected by building work?
- 03How do you make sure meals are served promptly, especially when the dining room is busy?
- 04How would you support my relative with one-to-one activities if they do not want to join group activities?
- 05How would you involve my relative and our family in care reviews, changing needs and end of life wishes?
This was a routine comprehensive inspection covering all five CQC questions and the overall quality of the home. This explanation was written from the published report of 2 February 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Westbourne Tower Care Home
2 rated inspections over 4 years: the service has slipped, from Outstanding to Good.
- February 2023Goodcurrent ratingdown from OutstandingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2019OutstandingSafe: GoodEffective: GoodCaring: OutstandingResponsive: OutstandingWell-led: Outstanding
- December 2017
Registered with the Care Quality Commission on 7 December 2017.
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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