CQC report explained · a residential care home
What the CQC found at Westdene Residential 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 improved risk records, fire safety arrangements, staffing levels, medicines systems and infection control.
- Effective?
- Good
- People's needs, nutrition and hydration were supported effectively. Staff training was up to date, and the home followed the principles of the Mental Capacity Act.
- Caring?
- Good
- This question was not given a separate rating in this follow-up inspection.
- Responsive?
- Good
- This question was not given a separate rating in this follow-up inspection.
- Well-led?
- Good
- Management oversight and record keeping had improved. Audits, feedback, complaints and incidents were used to monitor and improve the service.
What inspectors found, June 2022
Rated Good; inspectors found safe, effective and well-led care, with clear improvements since the previous inspection.
This was an unannounced follow-up inspection on 14 June 2022. One inspector spoke with people, relatives and staff, and reviewed care records, medicines records, staff files and management records.
The home was rated Good overall. Safe, Effective and Well-led were each rated Good. Inspectors found improvements in care records, fire safety, night staffing, staff training, medicines management and the dementia-friendly environment.
The previous inspection had rated the home Requires Improvement in October 2021. The provider had completed an action plan, and inspectors found the home was no longer in breach of regulations. Good means the inspection found consistently good care in the areas assessed, although some ongoing improvements were still identified.
Safer care records
Care records had improved and included people's needs, risks, preferences and choices. Inspectors found that records were regularly audited.
“Care records contained information about people's needs and risks.” from the report
Medicines management
Medicines were managed safely. Staff had medicines training and their competence was checked.
“Audits had been used effectively to help monitor and make sure medicines were managed safely.” from the report
Staff skills
Training, supervision and competency checks helped staff gain and maintain the skills needed for their roles.
“Staff training was up to date, which meant staff had the appropriate knowledge and skills to carry out their role.” from the report
Emergency planning
Fire safety systems, personal evacuation plans and regular drills had been improved so people's support needs would be considered in an emergency.
“Each person had a personal emergency evacuation plan to describe the support they would need in the event of a fire or other emergency situation.” from the report
Dementia-friendly changes
The home had added name boards and painted doors different colours to help people identify their rooms.
“Doors had been painted and name boards put in place to make the service is dementia friendly.” from the report
Remaining environmental work
minorInspectors noted that some further work was still needed to replace old furniture and improve decoration. This was being identified through audits.
“Audits carried out identified ongoing improvements required such as replacing old furniture and decoration.” from the report
- 01Which old furniture and decoration still need replacing, and when will this work be completed?
- 02How are night staffing levels reviewed against each person's needs?
- 03How often are medicines audits and staff competency checks completed?
- 04How are personal emergency evacuation plans kept up to date when people's needs change?
- 05How are people's views and relatives' feedback used to improve the home?
This was an unannounced follow-up inspection focused on improvements since the previous inspection, with infection prevention and control also checked under Safe; Caring and Responsive were not separately rated. This explanation was written from the published report of 30 June 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, October 2021
Rated Requires Improvement; inspectors found risks with fire safety, medicines, staff training, consent and quality oversight.
This was an unannounced inspection on 22 July and 2 August 2021. Inspectors spoke with people, relatives and staff, and checked care records, medicines, staff files and management records.
The home was not always safe or effective. Fire checks and evacuation guidance were incomplete, night staffing did not fully meet people's needs, medicines records were unreliable and staff training was out of date. Care records did not always reflect people's needs, including their food and fluid intake.
The home did not always follow the law about consent and best-interest decisions. Its systems for checking quality and safety had not identified the problems found by inspectors.
The overall rating changed from Good at the previous inspection to Requires Improvement. Safe, Effective and Well-led were all rated Requires Improvement. The report did not give separate ratings for Caring or Responsive.
People felt safe and supported
People and relatives said they were happy with the care and support. Staff knew how to recognise and report abuse.
“People and their relatives told us they were happy with the care and support they received.” from the report
Safe recruitment
The recruitment records checked by inspectors showed that systems were in place to help ensure staff were suitable to work with vulnerable people.
“Safe recruitment practises were in place to ensure staff were suitable to work with vulnerable people.” from the report
Infection control
Inspectors were assured about infection prevention and control, including PPE, testing, cleaning, distancing and visits.
“We were assured that the provider was using PPE effectively and safely.” from the report
Access to healthcare
People were supported to access healthcare services, and staff made referrals to other services when needed.
“People were supported to access healthcare such as GP's and dentists.” from the report
Fire safety
seriousFire checks and assessments were not up to date. Staff had not completed regular drills or received full training in evacuation equipment, and emergency plans lacked clear guidance for some people.
“People were placed at risk of harm because the provider had failed to ensure that fire safety systems were effectively managed.” from the report
Medicines
seriousMedicine policies were not always followed and records did not clearly show whether medicines had been given as prescribed. The home had not carried out the necessary medicine audits.
“Records did not always provide a clear and complete account of the support staff provided with people's medicines.” from the report
Consent and restrictions
seriousMental capacity assessments and best-interest decisions were poor. In some cases, decisions about lap belts had been made without showing that they were in the person's best interests or the least restrictive option.
“Decisions had been made without the consideration of whether it was in the person's best interests or the least restrictive option.” from the report
Care and fluid records
needs fixingCare records did not fully reflect people's needs. Food and fluid charts were inaccurate and were not properly monitored, including records saying two people had eaten when inspectors saw that they had not.
“Food and fluid charts were not completed correctly and were not monitored by senior staff to make sure people were having enough to eat and drink.” from the report
Night staffing and oversight
seriousNight staffing was not planned around people's support needs in an emergency. The provider's quality checks had also failed to identify several of the problems found by inspectors.
“The provider had failed to complete effective monitoring of the quality and safety of the service.” from the report
- 01What has been done to bring fire checks, fire assessments, staff drills and emergency evacuation plans up to date?
- 02How do you now check that medicines are given as prescribed and recorded accurately?
- 03Which staff training and supervision was overdue at the inspection, and has it now been completed?
- 04How are mental capacity and best-interest decisions recorded, especially for the use of lap belts?
- 05How have night staffing levels and checks on food and fluid records been changed since the inspection?
This was an unannounced inspection of the care, premises and management of the home; the report gives ratings for Safe, Effective and Well-led, while Caring and Responsive were not separately rated. This explanation was written from the published report of 16 October 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 Westdene Residential Home
3 rated inspections over 3 years: the service has held its Good rating throughout.
- June 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2021Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- July 2019GoodSafe: GoodEffective: GoodWell-led: Good
- July 2018
Registered with the Care Quality Commission on 2 July 2018.
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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