CQC report explained · a residential care home
What the CQC found at Westbury Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2023
Rated Requires Improvement; inspectors found unsafe medicine records, poor cleanliness and weak follow-through on improvements.
Inspectors visited without warning on 18, 20 and 21 April 2023. They spoke with all 8 people living there, relatives, staff and health professionals. They reviewed care, medicine, staff and management records.
They found medicines were not recorded accurately. The home was also not clean, and cleaning checks had not been completed. These problems created a risk of harm, although inspectors found no evidence that anyone had been harmed.
There were enough staff, people appeared comfortable with staff, and the home supported family contact and community activities. However, actions to fix earlier problems had not been kept in place.
The overall rating changed from Good to Requires Improvement. This was a focused inspection of Safe and Well-led. The other areas were not inspected and their previous ratings were carried forward.
Enough staff
Inspectors found there were enough staff to meet people's needs. Long-term temporary agency staff provided consistent support.
“There were enough staff to meet people's needs. People told us staff were available to provide support when they needed it.” from the report
People felt safe
People told inspectors they felt safe and were treated well. People appeared comfortable and at ease with staff.
“We observed people interacting with staff in a confident and comfortable way. People appeared at ease in the presence of staff.” from the report
Person-centred support
Staff were observed responding to people's individual needs. Professionals said staff knew people well and worked with them in a person-centred way.
“I think that they are person centred and know the people that live there, including their likes and dislikes, extremely well.” from the report
Family contact
People were supported to keep in touch with relatives and friends. Relatives said they could visit without restrictions.
“Relatives reported they could visit without restrictions, and staff supported people to keep in contact with them through phone calls.” from the report
Risk planning
Risk assessments were updated when people's needs changed and aimed to support independence as well as safety.
“Risk assessments and management plans had been reviewed and updated as people's needs changed.” from the report
Medicine records
seriousMedicine administration records had 78 gaps over four weeks. The home could not always show whether people had received prescribed medicines.
“The medicines administration record for the 4 week period starting 27 March 2023 contained 78 gaps.” from the report
Poor cleanliness
seriousInspectors found dirty bedrooms and shared areas, mould, smells of urine and food debris. Cleaning schedules existed but had not been completed.
“The service was dirty and the systems to maintain standards of hygiene were not effective.” from the report
Improvements not sustained
needs fixingThe provider had identified cleaning problems before, but the improvements had not lasted. This raised concerns about the home's quality monitoring.
“However, where shortfalls were identified, actions to improve the service were not always maintained and embedded in practice.” from the report
Choking guidance
needs fixingOne staff member was unclear about how to support a person at risk of choking. Senior staff gave guidance during the inspection and further training was planned.
“We identified one member of staff who was unclear of the support a person needed to manage the risk of choking.” from the report
- 01What has been done to prevent gaps in medicine administration records, and how are these records now checked?
- 02Have all areas identified as dirty, mouldy or damaged been cleaned or repaired, and how often are checks now completed?
- 03What evidence can you show that improvements identified in audits are being maintained?
- 04What extra training and checks have been completed for staff supporting people at risk of choking?
- 05Has the deputy manager vacancy been filled, and how is the registered manager's workload being managed?
This was an unannounced focused inspection of Safe and Well-led only; the other key question ratings were not inspected and were carried forward from the previous inspection. This explanation was written from the published report of 9 June 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, May 2021
Westbury Lodge was rated Good; inspectors found safe, well-managed care after investigating concerns about medicines, staffing and alleged abuse.
This was an unannounced, focused inspection on 18 March 2021. Inspectors looked at Safe and Well-led because concerns had been received about medicines, the management approach, staffing and alleged abuse. They spoke with people, relatives, staff and healthcare professionals, observed care and reviewed care, medicines, recruitment and management records.
The home was rated Good for Safe and Well-led. Inspectors found no evidence that people had been harmed because of the concerns they investigated. Medicines were managed safely, staffing had improved, safeguarding systems were understood and infection control arrangements were in place.
People were supported to be independent, take part in daily tasks and access local amenities. They could share their views through house meetings and individual discussions. The home had quality checks and action plans, although one care plan needed updating after the inspection and some professional correspondence was not answered promptly.
This inspection did not assess Caring, Effective or Responsive. Their previous ratings were used when calculating the overall rating, so the overall Good rating does not mean all five areas were reassessed during this visit.
Safe medicines
People received medicines as prescribed. Records had no gaps, storage temperatures were checked and staff had training and competency assessments.
“People had their medicines as prescribed. Medicines administration records (MAR) we reviewed had no gaps in recording.” from the report
Independence and choice
People were supported to live as independently as possible, including taking part in light domestic tasks, going into the local town and managing their own medicines where safe.
“People were supported to live as independently as possible.” from the report
Positive involvement
People could share their views in monthly house meetings or through individual discussions. Easy-read and pictorial information was provided where needed.
“Meetings were inclusive with everyone able to voice their views.” from the report
Learning and oversight
Incidents and accidents were reviewed, with learning shared with staff. The provider used audits, monthly visits and action plans to monitor improvements.
“Monthly governance meetings were held where all incidents and accidents were reviewed to identify any themes or trends.” from the report
Care plan update was delayed
needs fixingOne person's needs had changed after returning from hospital. Their care plan was updated after the inspection visit, rather than before it.
“One person had recently returned from hospital and their needs had changed. Their care plan required a review. This was completed following our site visit.” from the report
Some professional correspondence was not prompt
minorInspectors heard that the registered manager did not always respond to healthcare professionals' correspondence promptly. The provider said steps would be taken to improve this.
“We did hear feedback that the registered manager did not always respond to correspondence from professionals in a timely way.” from the report
- 01How quickly will you review and update a care plan when someone returns from hospital or their needs change?
- 02What system do you now use to make sure correspondence from healthcare professionals is answered promptly?
- 03What are the current ratings and most recent evidence for Caring, Effective and Responsive, which were not assessed in this inspection?
- 04How many agency staff are currently used, and when are they normally scheduled?
- 05How are people supported to manage their own medicines and take positive risks safely?
This was an unannounced focused inspection of Safe and Well-led only; the other key question ratings from previous comprehensive inspections were used to calculate the overall rating. This explanation was written from the published report of 1 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 Westbury Lodge
7 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- June 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2021Goodstayed GoodSafe: GoodWell-led: Good
- September 2017Goodup from Requires improvementSafe: Requires improvementWell-led: Good
- March 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2016Inadequatestayed InadequateSafe: Inadequate
- June 2016Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- January 2012
Registered with the Care Quality Commission on 30 January 2012.
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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