CQC report explained · a residential care home
What the CQC found at Westdene House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risks, medicines, staffing, recruitment and infection control were generally managed safely, although some laundry surfaces were difficult to sanitise.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward, but the report does not state that rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward, but the report does not state that rating.
- Responsive?
- Good
- Care was based on people's choices, routines and preferences. People were supported with communication, activities, relationships, complaints and access to the community.
- Well-led?
- Good
- The manager and staff created a positive, person-centred culture and worked with health and social care professionals. Quality systems had improved, but some inaccuracies in care records had not been found through audits.
What inspectors found, November 2022
Westdene House was rated Good; inspectors found safe, personal care, but some care records were inaccurate.
This was an unannounced focused inspection. Inspectors visited on 11 October 2022 and reviewed care, medicines, staffing, infection control, records and how the home was managed. They spoke with people, relatives, staff and health and social care professionals.
The home was rated Good overall. Safe, Responsive and Well-led were rated Good. Inspectors found enough trained staff, safe medicines arrangements, personalised care and positive relationships. People were supported to make choices, see relatives and take part in activities.
Some care records contained inaccuracies, including an incorrect malnutrition screening score and a record saying bedrails were in use when they were not. Inspectors said these had not harmed people and were corrected during the inspection. Some laundry surfaces were also difficult to sanitise, and the home had plans to upgrade the area.
People felt safe
People and relatives told inspectors they felt safe. Staff understood how to recognise and report possible abuse.
“People were protected from the risk of harm and abuse.” from the report
Enough familiar staff
Inspectors found enough staff to meet people's needs. Staff appeared relaxed, unhurried and familiar with the people they supported.
“Staff appeared relaxed and unhurried during the inspection and were available to assist people as requested.” from the report
Personalised support
Care plans recorded people's preferences, and staff knew their routines, histories and communication needs.
“People's care plans contained their choices and preferences.” from the report
Good relationships and activities
People were supported to see relatives, make friendships and join activities such as bingo and singing.
“We observed people engaging with a sing-along in the afternoon.” from the report
Improved leadership
Management systems had improved since the previous inspection. The previous governance breach had been resolved.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 17.” from the report
Care record inaccuracies
needs fixingAudits had not identified all inaccuracies in care records. Examples included an incorrect malnutrition screening score and a record saying bedrails were in use when they were not. Inspectors found no negative impact, and the records were corrected during the inspection.
“Quality assurance processes were in place; however, audits of care plans had not always identified some inaccuracies in some care records.” from the report
Laundry surfaces
minorThe home was clean, but some laundry surfaces were difficult to fully sanitise. The manager shared plans to upgrade the laundry area.
“The service was clean, however, some surfaces in the laundry area were impermeable making them difficult for staff to fully sanitise.” from the report
- 01What changes have been made to check care records for inaccurate information?
- 02Have all care plans now been rewritten and reviewed, especially for people with the highest support needs?
- 03Has the laundry area been upgraded so all surfaces can be fully sanitised?
- 04What were the ratings for Effective and Caring at the previous inspection?
- 05How will you make sure staff remain competent in specialist care, such as catheter care?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 9 November 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, December 2019
Rated Requires Improvement; inspectors found kind and effective care, but concerns remained about activities, equipment checks and management oversight.
This was a planned inspection on 15 and 16 October 2019 because of the previous rating. An inspector and an expert by experience spoke with people, a relative, staff and a visiting social worker. They also reviewed care, medicines, staffing and management records, and observed mealtimes and staff interactions.
People generally said they felt safe and cared for. Inspectors saw friendly, respectful staff, safe medicines practice, suitable staffing, good support with food and drink, and access to health professionals. The Effective and Caring ratings improved from Requires Improvement to Good.
However, some equipment safety checks were out of date. People were not always supported to take part in activities they chose, creating a risk of social isolation. Records about dietary needs were not consistent, and quality checks had not found some problems.
The overall rating stayed Requires Improvement, as did Safe, Responsive and Well-led. The home had improved since the previous inspection and was no longer in breach of Regulations 9, 10, 11 and 12. It remained in breach of Regulation 17 about good governance.
Kind and respectful staff
Inspectors observed friendly interactions and people appeared relaxed with staff. People and relatives said staff were kind and respectful.
“Staff interacted with people with kindness and respect.” from the report
Safe medicines support
Medicines records were accurate, medicines were stored securely, and staff stayed with people while they took their medicines.
“We reviewed medicine administration records (MAR) and saw these were accurate.” from the report
Food and hydration
People received varied homemade meals, snacks and drinks. Specialist diets and preferences were catered for, although documentation still needed improvement.
“There was a varied menu of homemade meals and people were complimentary about the meals served.” from the report
Improved consent and care planning
The home introduced capacity assessments and best-interest decision records. People, relatives and professionals were involved where decisions were needed.
“People's capacity had been assessed to make particular decisions.” from the report
Access to healthcare
Staff contacted relevant health professionals and supported people with appointments and specialist care when needed.
“Staff liaised effectively with other organisations and teams and people received support from specialised healthcare professionals when required” from the report
Overdue equipment checks
seriousChecks on equipment used by people were out of date. The provider took immediate action after inspectors raised this and arranged servicing.
“Checks on the safety of equipment used by people such as wheelchairs, hoists and slings were out of date.” from the report
Limited activities and social contact
needs fixingSome people said there was not much to do. People who spent time in their rooms did not have dedicated one-to-one visits from staff, increasing the risk of social isolation.
“people continued to not be supported to participate in activities of their choice and people continued to be at risk of social isolation.” from the report
Weak management checks
seriousAudits did not reliably find problems, including missing handwashing materials and gaps in medicines checks. The provider needed better oversight of care quality and equipment servicing.
“There was an inadequate process for assessing and monitoring the quality and safety of the care provided” from the report
Dietary records
minorPeople's dietary needs were supported, but the information was not reflected consistently across all documentation.
“ensuring that dietary needs were reflected across all documentation was an area of improvement.” from the report
- 01What is the current schedule for servicing wheelchairs, hoists, slings and the stairlift, and how do you check that no service is missed?
- 02How do you make sure each person has regular activities that match their interests and choices?
- 03How do staff provide one-to-one time for people who prefer to stay in their rooms?
- 04How are dietary needs checked across care plans, kitchen records and daily staff information?
- 05What changes have you made to your audits since inspectors found that they had missed missing handwashing materials and gaps in medicines checks?
This was a planned inspection covering all five CQC questions, following the previous Requires Improvement rating. This explanation was written from the published report of 12 December 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 Westdene House
4 rated inspections over 6 years: the service has held its Good rating throughout.
- November 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2019Requires improvementstayed Requires improvementSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Registered with the Care Quality Commission on 10 October 2014.
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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