CQC report explained · a residential care home
What the CQC found at Westerley Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, July 2022
Westerley Care Home is rated Good; inspectors found safe, effective care and supportive leadership, with clearer quality records still needed.
This was an unannounced focused inspection. Inspectors visited on 16 May 2022 and reviewed information, care records, medicines records, staff files, training records, audits and meeting notes. They spoke with people, relatives and staff.
The home was rated Good overall. Safe, Effective and Well-led were also rated Good. Inspectors found enough staff, safe medicine practices, suitable risk assessments, trained staff and good support for people's choices, health and nutrition.
The inspection followed concerns about safeguarding and staffing. The previous overall rating was Requires Improvement, published on 10 March 2021. The rating improved to Good after this inspection.
The home had systems to monitor quality, but records did not always clearly show what action had been taken after checks. The provider agreed to improve the audit trail. Inspectors also asked for conditions from legal authorisations to be added to care plans.
Enough staff
Inspectors found sufficient staff on duty. Staff were attentive and responded promptly when people needed help.
“There were sufficient staff deployed, we observed that staff were attentive and able to respond promptly to people.” from the report
Safe medicines
Medicines were given as prescribed, records were accurate and stock balances were correct. Staff training and regular audits supported this.
“Medicines were managed safely. People were receiving their medicines as instructed by the prescriber and all records reviewed were completed accurately.” from the report
Personalised support
Care plans covered people's needs, preferences and personal history. People were supported to make choices about care, meals and their daily lives.
“People's needs and choices were assessed before admission to the service and they were supported to express their views and preferences regarding their care.” from the report
Supportive management
People, relatives and staff spoke positively about the management team. Staff had regular meetings, handovers and supervision.
“People, relatives and staff spoke positively about the management of the service.” from the report
Quality records
needs fixingAudits and checks were completed, but the records did not consistently show what action had been taken after findings. The provider was planning clearer audit trails.
“records completed did not consistently evidence the action taken in response to any findings.” from the report
Conditions in care plans
minorInspectors asked the provider to include conditions from Deprivation of Liberty Safeguards authorisations in care plans, so staff could see them clearly.
“We asked the provider to ensure that any conditions from authorisations were included within care plans to ensure that all staff were aware of them.” from the report
- 01How are you improving the records that show what action was taken after quality audits?
- 02How do you make sure any conditions attached to legal authorisations are included in each person's care plan?
- 03What were the previous ratings for Caring and Responsive, which were not inspected during this visit?
- 04How do you check that staffing levels continue to match the needs of the people living here?
- 05How are feedback from relatives and staff used to make changes?
This was a focused inspection of Safe, Effective and Well-led only; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 16 July 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, March 2021
Targeted inspection found improvements, but the home remained Requires Improvement overall and was not re-rated.
This was an unannounced targeted inspection on 22 January 2021. The inspector checked whether earlier problems with safe care, infection control, risk management and quality checks had been fixed. They reviewed records, observed care and spoke with people, relatives, staff and professionals.
Inspectors found enough improvement in risk management, infection control and management oversight. They said the home was no longer in breach of Regulations 12 and 17. People and relatives said they felt safe and praised the care and communication.
There was still a concern about social distancing. People were sitting close together, so the provider was asked to follow current guidance and create more controlled areas for people who walked with purpose.
The inspection did not assess the full Safe or Well-led questions, so these were marked inspected but not rated. The previous overall rating of Requires Improvement remained in place.
Improved safety arrangements
Risk assessments were used for areas such as falls, smoking and weight loss. Inspectors found enough improvement for the earlier breach relating to safe care and treatment to be removed.
“Enough improvement had been made at this inspection and the provider was no longer in breach of Regulation 12.” from the report
Improved management checks
Audits, cleaning schedules and daily checks helped managers monitor the home and identify improvements. The earlier breach relating to good governance was no longer present.
“Enough improvement had been made at this inspection and the provider was no longer in breach of Regulation 17.” from the report
People felt safe
The person spoken with and relatives who provided feedback said people were safe and well looked after.
“Everyone who wrote to us felt that people were safe and well looked after in the home.” from the report
Good communication
Relatives said staff helped people keep in touch through video calls and praised communication from staff and management during lockdown.
“Relatives told us staff made efforts to facilitate video calls and face time with people in the home throughout lockdown.” from the report
Social distancing
needs fixingInspectors saw that people were sitting close together. They asked the provider to follow current guidance and create more controlled areas for people who walk with purpose.
“We recommended that the provider refers to current guidance and best practice around implementing social distancing and create more controlled areas for people who walk with purpose” from the report
- 01What has changed since the inspection to make sure people can keep a safe distance from each other?
- 02How are controlled areas used for people who walk with purpose?
- 03What actions were completed after the earlier breaches of Regulations 12 and 17?
- 04When will the home have a full comprehensive inspection?
- 05How are infection control audits and daily cleaning checks reviewed now?
This was a targeted inspection of specific concerns about infection prevention, risk management and governance; it did not assess the full Safe or Well-led questions, and the previous overall rating of Requires Improvement carried over. This explanation was written from the published report of 10 March 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 Westerley Care Home
3 rated inspections over 6 years: the service has held its Good rating throughout.
- July 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Good
- March 2021Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- May 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- August 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 24 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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