CQC report explained · a residential care home
What the CQC found at Westfield House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2023
Abbeyfield Loughborough was rated Inadequate and placed in special measures after inspectors found serious risks to people's safety, care and management.
This was an unannounced follow-up inspection on 26 September 2023. Two inspectors and two Experts by Experience spoke with people, relatives and staff. They observed care, meals, medicines and activities, and reviewed care records, medicine records, staff files, training and management checks.
Inspectors found people were at risk of harm because known risks were not properly assessed or managed. Staffing was not sufficient, some medicines were not managed safely, and staff did not have the skills needed to support people with complex dementia and distressed behaviour. People were not always supported with food, drinks, hygiene, oral care or safe movement.
The home did have some safer practices. Staff recruitment checks had been completed. Infection prevention arrangements were mostly satisfactory, and people could have visitors without restrictions. However, the overall findings showed widespread and serious shortfalls.
The overall rating was Inadequate. Safe, Effective and Well-led were each rated Inadequate. The home was placed in special measures, meaning CQC will keep it under review and normally re-inspect within six months if the provider's registration is not cancelled.
Safer recruitment
The provider carried out references and criminal record checks when recruiting staff.
“Staff were recruited safely. The provider requested references from previous employment and the employees' Disclosure and Barring Service (DBS) status had been checked.” from the report
Infection prevention
Inspectors were assured about several infection prevention arrangements, including preventing visitors from spreading infections and responding to infection risks.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Access to healthcare
People were supported to see GPs and other health professionals, including speech and language therapy services.
“Care records showed people were supported to access the GP and other healthcare services, such as speech and language therapy.” from the report
Visitors allowed
The home allowed visitors without restrictions at the time of the inspection.
“The home was open for visitors with no restrictions in accordance with the current guidance.” from the report
People were at risk of harm
seriousKnown risks, including distress, falls, injuries and unsafe moving and handling, were not properly managed. Staff were seen pulling a person up by their clothing, and another person was not supervised despite known risks of injury.
“The lack of proper risk assessment, risk management plans and care plans exposed people using the service to risks of avoidable harm.” from the report
Not enough suitable staff
seriousStaffing levels and deployment did not consistently meet people's needs. People were left without enough help with meals, drinks, personal care, repositioning and supervision.
“The provider had failed to ensure there were sufficient numbers of suitably qualified, competent, skilled and experienced staff deployed to support people to stay safe and meet their needs.” from the report
Unsafe medicines management
seriousSome as-required medicines did not have clear instructions, stock records were inaccurate, and covert medicines were not supported by recorded best-interest decisions.
“The provider had failed to ensure the proper and safe management of medicines.” from the report
Insufficient dementia training
seriousStaff had only basic training and lacked the knowledge and skills to support people with complex dementia and distressed behaviour safely.
“The provider had failed to ensure that staff received training, and supervision as is necessary to enable them to carry out their duties.” from the report
Consent and best interests
seriousRelatives and other people had given consent without the required legal authority. DoLS conditions were not consistently followed, and staff did not consistently apply the Mental Capacity Act.
“The provider had failed to ensure care and treatment was provided with consent of the relevant person and to act in accordance with The Mental Capacity Act 2005.” from the report
Weak management oversight
seriousAudits and checks did not identify serious problems with care, staffing, risks, records or legal requirements. There was no registered manager in post.
“The provider had failed to ensure adequate systems and processes were in place to assess, monitor and improve the quality and safety of the care provided.” from the report
- 01What immediate changes have been made to staffing levels and staff deployment, especially for people who need one-to-one supervision or two staff for mobility?
- 02What training and supervision have staff now received for complex dementia, distressed behaviour, physical interventions and moving and handling?
- 03How are medicines, including as-required and covert medicines, now checked and recorded?
- 04How are risks, accidents, falls, injuries and safeguarding incidents reviewed, and how are relatives informed about what happened?
- 05Who is currently responsible for management oversight, and what evidence can you show that the urgent registration conditions are being met?
This was an unannounced follow-up inspection after the previous Requires Improvement rating; ratings were given for Safe, Effective and Well-led, while the report does not give ratings for Caring or Responsive. 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, April 2023
Rated Requires Improvement; inspectors found unsafe gaps in risk records and weak oversight, although medicines and staffing were generally safe.
The unannounced inspection took place on 25 January 2023. Inspectors spoke with people, relatives and staff, observed care, and checked care records, medicines, recruitment files, training records and management records.
The home was not always safe. Risk assessments did not give staff enough detail, and records of skin checks and repositioning had gaps. Some behaviour support plans also lacked clear guidance. Mental capacity assessments needed improvement.
Medicines were managed safely, there were enough staff to meet people's needs, and staff understood safeguarding procedures. However, agency staff checks, cleaning standards and fire drills needed further attention.
The home was not well-led because audits and checks were inconsistent and did not always identify problems. The overall rating fell from Good at the previous inspection to Requires Improvement. The provider was asked for an action plan and CQC will monitor progress.
Medicines
People received their medicines safely and records were accurate and complete. Staff had training and their competence was checked.
“People received their medicines safely and as prescribed.” from the report
Staffing levels
Inspectors saw enough staff available to meet people's needs and spend time talking with and reassuring them.
“We observed there were enough staff to meet people's needs and spend time with people talking and reassuring them.” from the report
Safeguarding
Staff knew how to report concerns, and the provider worked with the local authority and CQC when needed.
“Staff had received safeguarding training and understood what to do if they had any concerns.” from the report
Respectful care
Staff regularly sought people's views about their care and how they wanted to spend their time.
“We observed staff consistently sought people's views and opinions about how they wanted their care to be provided and how they wanted to spend their time.” from the report
Risk assessment gaps
seriousRisk assessments did not always explain the equipment and steps needed to reduce risks. Records of skin checks and repositioning were incomplete.
“The provider had not effectively assessed and managed risks to people's health and safety.” from the report
Behaviour support plans
needs fixingSome plans did not explain how staff should respond when people became distressed, including how to use timely and least restrictive approaches.
“Some plans lacked detailed guidance around interventions and responses.” from the report
Weak quality checks
seriousAudits and checks were not consistently completed, so problems in care records, risk assessments and agency staff checks were not always found.
“The provider did not have robust processes in place to monitor the safety and quality of the service.” from the report
Agency staff checks
needs fixingAgency staff profiles were not always available, so the home could not always show that agency workers had the specialist skills and knowledge needed.
“Agency staff profiles were not always available for staff who were working in the service.” from the report
- 01What changes have been made to risk assessments for moving and handling, skin integrity and repositioning?
- 02How do you now make sure daily skin checks and repositioning records are completed accurately?
- 03How are behaviour support plans updated so staff know how to respond when someone becomes distressed?
- 04How do you check that agency staff have the specialist skills and knowledge needed for this home?
- 05What action plan followed the two breaches, and what improvements have been completed?
This inspection focused on Safe and Well-led, including infection prevention and control; the other key question ratings were not given in this report. This explanation was written from the published report of 5 April 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.
Every inspection of Westfield House
6 rated inspections over 9 years: the service has slipped, from Good to Inadequate.
- December 2023Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: InadequateCaring: GoodResponsive: GoodWell-led: Inadequate
- April 2023Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- December 2021Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- February 2020Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- July 2017Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 2 December 2010.
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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At least 100 live-in carers within about an hour of Leicestershire
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.
Most charge £980 to £1,260 a week. 82 can care for a couple. 12 years' experience on average.
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