What the CQC found at Westerleigh

People and relatives spoke positively about the care. Inspectors observed staff treating people with empathy and compassion.

“We observed staff interact with people in a kind and compassionate manner.” from the report

People said they felt safe, and staff knew people well and understood how to protect them from abuse.

“People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse.” from the report

The management team had recognised the problems and was working with staff to improve practice. Audits were described as honest and robust.

“The management team were now completing regular audits, which were robust and an honest reflection of the service.” from the report

The home had an active recruitment programme and appropriate checks were being carried out.

“An active recruitment programme was in place and appropriate checks were made.” from the report

The local authority had been monitoring the home since 2021 because medicines were not always managed safely and effectively. Staff competencies had been reviewed and an action plan was under way.

“Since 2021 the local authority had been closely monitoring the service due to difficulties staff had around ensuring medicine management was effective and safe.” from the report

Many electronic risk assessments had not been completed. Those that were present did not always give enough detail about people's risks and needs.

“Many of the risk assessments on the electronic care records had not been completed and those in place, needed to be more detailed and outline the full range of presenting issues.” from the report

The staffing dependency tool was not used consistently, which resulted in different staffing levels across shifts. Staff also reported feeling stretched.

“This had led to variations in staffing levels across shifts.” from the report

Records did not always make clear whether incidents had been reported to the right authorities. Staff were also not completing incident analysis and lessons-learned tools.

“However, at times it was unclear from the records whether all incidents had been reported to appropriate authorities, or if staff always recognised the need to record and report incidents.” from the report

Staff did not feel confident applying the Mental Capacity Act. Records showed gaps in understanding about capacity assessments and best-interest decisions.

“Staff did not feel confident when applying the Mental Capacity Act 2005 and associated code of practice to their practice.” from the report

There was no registered manager at the time of the inspection. The recent management changes had identified significant practice problems, and improvements were not yet fully embedded.

“At the time of our inspection a manager was not yet registered with the Care Quality Commission.” from the report