CQC report explained · a residential care home
What the CQC found at Westerley Residential Care Home for the Elderly - Woodhall Spa
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2023
Westerley Residential Care Home for the Elderly - Woodhall Spa was rated Inadequate and placed in special measures because inspectors found serious safety, care and management failures.
This was an unannounced focused inspection in August and September 2023. Inspectors spoke with people, relatives, staff and healthcare professionals. They reviewed care and medicines records, staff files, training information and quality checks.
Inspectors found that risks were not managed safely. Staffing levels were often below the level set by the provider. Medicines records and medicines checks were not reliable. Some areas were unclean, fire safety checks were not consistently completed, and care records did not always describe people's current needs and risks.
People did not always receive the right support with falls, eating, drinking, choking risks, healthcare or restrictions on their liberty. Staff training and induction were incomplete. The provider's audits and oversight had not found or fixed many problems. Safe, Effective and Well-led were all rated Inadequate. Caring and Responsive were not inspected during this visit, so their previous ratings were carried forward.
Visitors were welcomed
Friends and relatives were able to visit, and inspectors saw that visitors were made welcome by staff.
“when relatives and friends visited, they were made welcome by staff.” from the report
Some positive views of staff
Most people and relatives who spoke with inspectors were happy with the care and staff competence, despite the wider concerns.
“Most people and relatives were happy with the care provided and the competence of staff working at the home.” from the report
Some partnership working
Inspectors saw some work with community agencies, and professionals described most staff as friendly and approachable.
“Two community professionals who visited the home told us most staff were friendly and approachable, and people seemed well cared for” from the report
People were at risk of harm
seriousThe home environment was not consistently safe. Inspectors found problems with water temperatures, fire safety, window restrictors, staircases, radiators, falls monitoring and care records.
“The provider had failed to ensure the safety of the home environment and that risks to people's health, safety and welfare were managed appropriately.” from the report
Not enough staff
seriousRotas showed that staffing was often below the provider's own expected level. People and relatives said support was delayed because staff were too busy.
“The staff are nice. They try their best, there's just not enough of them.” from the report
Medicines were not managed safely
seriousMedicine stocks did not always match records, some handwritten records were unsigned, and medicine errors were not dealt with properly. Audits had not fixed repeated problems.
“Medicines were not managed safely, in line with National Institute for Health and Care Excellence (NICE) guidance.” from the report
Care and training gaps
seriousCare records did not always contain current information about people's needs, including nutrition and choking risks. Staff induction was not documented and mandatory training compliance was only 61%.
“The provider had failed to ensure that staff had the knowledge and skills to meet people's needs effectively.” from the report
Legal safeguards were not followed
seriousSome capacity assessments and best-interest decisions were missing. Applications for authorisation had only been made for 3 of the 9 people identified as being deprived of their liberty.
“The provider had failed to ensure people were supported in line with the principles of the MCA and the necessary authorisation had been sought to restrict people's liberty.” from the report
Poor management oversight
seriousMany problems had not been identified or acted on by the manager or provider. Audits were missing or ineffective, and some required notifications had not been sent to CQC.
“Many of the issues and shortfalls we found during our inspection had not been identified by the manager or provider, so improvements had not been made when needed.” from the report
- 01What has been done to make the premises safe, including fire safety, staircases, window restrictors, water temperatures and radiator protection?
- 02What staffing levels are now in place on every shift, and how are they matched to the needs and risks of all residents?
- 03How are medicines checked now, and how are errors, missing signatures and mismatches between stock and records prevented?
- 04Which staff have completed training in safeguarding, fire safety, falls, infection control, food hygiene and swallowing risks?
- 05For residents who may lack capacity, have capacity assessments, best-interest records and all required liberty restriction applications now been completed?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 15 December 2023 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, November 2022
Rated Requires Improvement; inspectors found risks, staffing, training and management systems that need urgent attention.
This was an unannounced focused inspection on 25 August and 1 September 2022. Inspectors spoke with people, relatives and staff, observed care, and checked care records, medicines records, training information and quality checks.
The home was not always safe or effective. Risk assessments and care records were not always up to date, medicines checks were incomplete, infection control had weaknesses, and there were not always enough support staff. People's nutrition and hydration needs were not consistently monitored.
Staff did not always have up-to-date training. The home was also not following the Mental Capacity Act properly in some cases, including missing capacity assessments and applications for Deprivation of Liberty Safeguards. Management checks had not identified or fixed several of these problems.
The overall rating fell from Good at the previous inspection in February 2019 to Requires Improvement. CQC identified breaches of regulations and will monitor an action plan from the provider.
Safe recruitment
The home had recruitment checks designed to help ensure staff were suitable to work there.
“Safe staff recruitment processes were in place.” from the report
Safeguarding follow-up
When safeguarding concerns were reported to management, the home worked with the local safeguarding team and acted on investigation outcomes.
“Where any safeguarding concerns had been raised to the registered manager, they had worked with the local safeguarding team to investigate the concerns and act on the outcome of investigations.” from the report
Visiting arrangements
The home supported visits in line with government guidance, and relatives said visiting was facilitated.
“The service facilitated visits in line with government guidelines.” from the report
Unmanaged safety risks
seriousSome risks were not properly assessed or managed. These included falls, access to staircases, access to insulin equipment and movement around other people's bedrooms.
“The risks to people's safety were not always fully identified and some assessment tools used were not regularly updated to ensure people's current needs were reflected.” from the report
Medicines records and storage
seriousThere were unexplained gaps in medicines administration records and incomplete temperature checks for medicines storage.
“There were unexplained gaps in people's medicines administration records (MAR) from the previous month where medicines had either not been administered or not signed for.” from the report
Staffing and delays
seriousCare staff also had to serve meals, manage laundry and clean. People and relatives reported long waits for call bells, personal care, toileting and going to bed.
“One person told us there were times they had needed to wait almost two hours for staff to respond to their call bell.” from the report
Training gaps
needs fixingSome staff had not completed up-to-date training in areas including safeguarding, food hygiene, nutrition, hand hygiene and COVID-19.
“The training matrix showed some staff had not received up to date safeguarding adults training, safety in catering /food hygiene training, nutrition and hydration training, hand hygiene training and COVID 19 training.” from the report
Nutrition monitoring
seriousPeople were not weighed regularly. A person's nutrition score indicated weekly weighing and other actions, but these had not been completed.
“People had not been weighed on a regular basis; the monthly weight sheets showed people had last been weighed in November 2021.” from the report
Weak management checks
seriousCare records, cleaning systems and audits were incomplete or inaccurate. Provider monitoring had not found several of the problems identified by inspectors.
“There was a lack of effective oversight of the service.” from the report
- 01How many care and ancillary staff are now on duty at busy times, evenings and weekends?
- 02What checks now show that medicines are administered, recorded and stored at the correct temperatures?
- 03How are falls, access to staircases, sensor mats and insulin equipment assessed and reviewed?
- 04How do you check that staff have completed current safeguarding, nutrition, food hygiene, hand hygiene and COVID-19 training?
- 05What has changed to ensure mental capacity assessments, best-interest decisions and Deprivation of Liberty Safeguards applications are completed when needed?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and the previous ratings were used to calculate the overall rating. This explanation was written from the published report of 16 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.
Every inspection of Westerley Residential Care Home for the Elderly - Woodhall Spa
4 rated inspections over 7 years: the service has slipped, from Good to Inadequate.
- December 2023Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: InadequateCaring: GoodResponsive: GoodWell-led: Inadequate
Read what inspectors found at Westerley Residential Care Home for the Elderly - Woodhall Spa →
- November 2022Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
Read what inspectors found at Westerley Residential Care Home for the Elderly - Woodhall Spa →
- February 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- June 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 12 January 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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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.