CQC report explained · a nursing home
What the CQC found at Westcombe Park Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors reviewed infection prevention and control only. They were assured about PPE, testing, visiting, cleaning and managing infection outbreaks.
- Effective?
- Good
- People's needs and consent were managed lawfully. Staff had received improved training and competency checks, and people's nutritional and healthcare needs were supported.
- Caring?
- Good
- This key question was not covered by this focused inspection.
- Responsive?
- Good
- Care plans reflected people's wishes, communication needs, culture, faith, sexuality and gender identity. People had access to activities, relationships and personalised end of life care.
- Well-led?
- Good
- The home had stronger audits, communication and learning systems. People, relatives and staff spoke positively about the new manager and the improvements being made.
What inspectors found, July 2021
Rated Good; inspectors found kind, personalised care and major improvements since the last inspection, while Safe was inspected but not rated.
This was an unannounced focused inspection on 23, 28 and 30 June 2021. Inspectors spoke with people, relatives, staff and health professionals. They observed care and reviewed care plans, audits and other records.
The home had improved since the previous inspection, which was rated Requires Improvement. Staff training and support had been strengthened. Records about consent and legal restrictions had improved. Care was personalised, activities had increased and quality checks were more effective.
The home was rated Good overall. Effective, Responsive and Well-led were rated Good. Safe was inspected only for infection prevention and control, so it was not rated at this visit. The previous Safe rating of Good was carried forward. Caring was not covered by this focused inspection.
Cleanliness and infection control
Inspectors were assured that the home managed infection risks effectively. They also found enhanced cleaning of high-risk touch areas and dedicated rooms for putting on and removing protective equipment.
“I would give them top marks for cleanliness and their Covid-19 measures.” from the report
Better staff training
The home had improved training, induction, supervision and competency checks. Training included areas previously identified for improvement, such as dementia and end of life care.
“All staff received training and had their competencies assessed across range of areas such as medicines, MCA and falls prevention.” from the report
Personalised care
Care plans reflected people's preferences, communication needs, background and relationships. Staff used communication aids and adapted information where needed.
“People and their relatives told us the care they received was personalised to them and addressed their preferences and needs including in respect of their culture, faith, sexuality and gender identity.” from the report
Support at the end of life
End of life plans included people's wishes, pain relief and spiritual needs. Staff had received additional training with a local hospice and other providers.
“People received dignified and personalised end of life care that met their needs.” from the report
Stronger management oversight
Audits were detailed and carried out consistently. The manager and provider reviewed incidents, complaints and accidents so that learning could lead to changes.
“There was an effective system to monitor the quality and safety of the service.” from the report
Some daily checks were not consistent
minorStaff had not always completed daily temperature checks as required. The manager used daily reminders until this became consistent.
“Where staff had not always completed their daily temperature checks as required, the manager sent daily reminders until staff maintained the practice consistently.” from the report
Some involvement plans delayed
minorThe pandemic had delayed progress on some aims in the people's involvement charter, including fetes and parties. The manager said they hoped to develop this further.
“Progress on some objectives had been hampered by the pandemic for example people's involvement in fetes or parties, but the manager told us they hoped to develop this further over time.” from the report
- 01How do you now check that staff complete daily temperature checks and other routine safety checks?
- 02What progress has been made with the people's involvement charter since the pandemic restrictions?
- 03How will you involve my relative in planning and reviewing their care?
- 04How are staff competencies in medicines, falls prevention, dementia and end of life care kept up to date?
- 05What infection control arrangements and visiting procedures are currently in place?
This was a focused inspection of Effective, Responsive and Well-led, plus infection prevention and control under Safe; the previous Safe rating was carried forward and Caring was not assessed. This explanation was written from the published report of 31 July 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, April 2021
Westcombe Park Care Home was inspected but not rated; inspectors found good infection control and clean premises.
This was an announced, targeted inspection on 29 March 2021. It checked how the home prevented and controlled infections during the COVID-19 pandemic, including a previous concern about kitchen fridges.
Inspectors found the home clean and hygienic. They were assured that cleaning, visitor checks, protective equipment, testing and infection control policies were being managed safely.
The home supported safe visits and helped people keep in touch with family using audio and video technology. The service was inspected but not rated, so this report does not give a full quality rating.
Clean premises
Inspectors found the home clean and hygienic, including the fridges that had been the subject of a possible concern.
“We were assured of the levels of cleanliness throughout the home, including the fridges on all floors and in the main kitchen.” from the report
Safe visiting
Visitors were screened, supported to use protective equipment and social distance, and safe visiting areas were cleaned after use.
“Procedures were in place for visits to the home to be carried out safely, in line with national guidance.” from the report
Infection control training
Staff had updated infection control training and access to protective equipment. The home also had arrangements for COVID-19 testing.
“Staff had received training in infection control which had been updated to include information on managing the risk of the spread of COVID-19 and the use of PPE.” from the report
Family contact
People were supported to stay in regular contact with family and friends through audio and video technology.
“People were also supported to maintain regular contact with their friends and family members using a range of audio and video technology.” from the report
Inspectors raised no specific concerns in this report.
- 01How are kitchen fridges and other high-touch areas cleaned and checked now?
- 02How are visitors currently screened and supported to use protective equipment and follow distancing guidance?
- 03How often are people and staff tested for COVID-19, and who carries out the tests?
- 04What infection control training do staff receive now, and when was it last updated?
- 05What are the current arrangements for helping residents keep in contact with family and friends?
This was a targeted inspection of infection prevention and control during the COVID-19 pandemic; it did not provide a full rating of the home. This explanation was written from the published report of 29 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.
Every inspection of Westcombe Park Care Home
10 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- July 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2021Inspected but not ratedSafe: Inspected but not rated
- September 2019Requires improvementstayed Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2018Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- August 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2016Requires improvementstayed Requires improvementWell-led: Requires improvement
- June 2016Requires improvementup from InadequateSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2016Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2015Requires improvementstayed Requires improvementSafe: InadequateEffective: Requires improvement
- June 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 21 March 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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