CQC report explained · a nursing home
What the CQC found at Westgreen House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risks linked to distressed behaviour, medicines, falls and skin damage were not always fully assessed or managed. There were also concerns about staff deployment and one incident was not promptly reported to CQC.
- Effective?
- Requires improvement
- Some staff were not suitably trained or assessed as competent to support distressed behaviour safely. The principles of the Mental Capacity Act were not always followed or clearly recorded.
- Caring?
- Good
- People and relatives said staff were caring, kind and friendly. Inspectors saw people treated with dignity and supported to make choices.
- Responsive?
- Requires improvement
- Care did not always reflect people's current needs, preferences or communication needs. Some people had limited meaningful interaction, and concerns were not always recorded consistently.
- Well-led?
- Requires improvement
- Quality monitoring did not identify several important shortfalls in care, risk management, reporting and complaints. Changes to the management team were linked to some reported improvement, but governance systems were still not effective enough.
What inspectors found, June 2022
Rated Requires Improvement; inspectors found kind care, but important risks, care planning and management systems were not always handled safely.
This was the home’s first rated inspection under the current provider. It was unannounced and took place on 18 and 19 May 2022. Inspectors spoke with people, relatives, staff and managers, and checked care records, medicines, training and management records.
The home was caring in its approach. People and relatives described staff as kind and friendly. Medicines were generally managed safely, people could see health professionals, infection control arrangements were in place, and there were no visiting restrictions.
However, inspectors found important shortfalls. Risks were not always properly assessed or managed. Some staff lacked suitable training for supporting distressed behaviour. Care plans were not always up to date or personalised, and quality checks had not found or corrected these problems.
The overall rating Requires Improvement means the home was not consistently providing safe, effective, responsive or well-led care. The provider must send an action plan, and CQC said it would continue to monitor progress.
Kind and respectful staff
People and relatives described staff as caring, kind and friendly. Inspectors found that staff maintained people's dignity and privacy.
“People and relatives described the staff as "caring", "kind" and "friendly".” from the report
Medicine arrangements
Medicines were administered by trained staff, stored safely and reviewed regularly. Arrangements were in place for time-sensitive medicines.
“People's medicines were managed and administered by trained staff.” from the report
Healthcare support
People had access to GPs and other healthcare professionals when needed. Referrals were made when people's health deteriorated.
“A GP visited weekly and more often if required.” from the report
Infection control and visiting
Inspectors were assured about most infection prevention arrangements. Relatives and friends could visit without restrictions at the time of inspection.
“Visiting for people's relatives and friends was in line with government guidance; there were no restrictions in place.” from the report
Activities matched to interests
The activities co-ordinator tried to find out what people enjoyed and adapted activities to their preferences, including for someone who was bed-bound.
“They tried to adjust what they provided so it met people's individual preferences.” from the report
Risks were not always managed
seriousRisk records did not always reflect people's needs or the actions staff were taking. Inspectors found problems involving distressed behaviour, pressure damage, a sensor mat, falls, blood-thinning medicine and diabetes.
“Risks to people had not always been fully identified and assessed.” from the report
Unsafe support for distressed behaviour
seriousStaff used restrictive practices and medicines to calm one person, but these actions were not always assessed, recorded or supported by suitable training.
“Staff were not suitably trained and assessed as competent to deliver this type of support.” from the report
Care plans were out of date
needs fixingSome care plans did not describe people's current needs, including personal hygiene support and covert medicines. This could result in staff giving unsuitable care.
“Some people's care plans had not been updated sufficiently to ensure staff had updated information on how to meet people's needs when their needs altered.” from the report
Limited communication and social contact
needs fixingSome people did not receive enough help to understand information or make choices. Inspectors also saw missed opportunities for conversation and social interaction.
“Some people told us they missed the opportunity for meaningful interaction.” from the report
Weak quality checks
seriousThe provider's audits did not identify several problems found by inspectors, including shortfalls in risk planning, care delivery, incident reporting and complaints records.
“Governance systems were not always operated effectively to ensure people remained safe and received a good quality service.” from the report
- 01What action has been taken to assess and manage risks involving distressed behaviour, falls, pressure damage, blood-thinning medicines and diabetes?
- 02What certified training have staff completed for restrictive practices and supporting people with distressed behaviour?
- 03How do you make sure each person's care plan is updated promptly when their needs or medicines change?
- 04How are staffing levels and staff deployment checked during busy periods so everyone receives support when needed?
- 05What changes have been made to quality audits, incident reporting and recording complaints since this inspection?
This was an unannounced first rated inspection covering all five key questions, including infection prevention and control; no previous rating was available under the current provider. This explanation was written from the published report of 18 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, December 2020
Inspected but not rated; inspectors were assured that infection control measures were in place.
The CQC visited the home on 30 November 2020 as part of a planned coronavirus infection control review. The visit was announced and focused only on preventing and controlling infection.
Inspectors found the home clean, with cleaning schedules, hand and protective equipment stations, visitor checks and a separate area for visits. People and staff were supported with regular coronavirus testing.
The home had a separate wing for anyone who tested positive, and staff had procedures for uniforms, footwear, social distancing and protective equipment. Inspectors said they were assured that infection prevention measures were being followed.
The service was inspected but not rated. This report does not give an overall quality rating or ratings for care, staffing, medicines, activities or management.
Clean environment
Inspectors found the home clean and without unpleasant smells. A cleaning schedule was in place for all areas.
“The service was clean and free of malodour. There was a cleaning schedule in place to ensure that all areas of the service were cleaned.” from the report
Safe visiting arrangements
Visitors were checked for symptoms and supported to follow infection control and protective equipment guidance. A separate indoor visiting area had its own entrance and protective equipment station.
“Visitors were supported by staff to ensure they followed safe infection control, PPE guidance and to check whether they had any symptoms of coronavirus before entering the home.” from the report
Regular testing
People living in the home and staff were supported with regular coronavirus testing. New admissions were tested on arrival.
“People were supported to receive regular testing for Covid-19.” from the report
Plans for infection outbreaks
The home had a separate wing intended for people who tested positive for coronavirus, to help reduce the risk of infection spreading.
“The service had developed a COVID-19 secure wing to accommodate anyone who may test positive for coronavirus.” from the report
Inspectors raised no specific concerns in this report.
- 01How have the infection control arrangements described in the report been maintained or changed since the inspection?
- 02Is the separate indoor visiting area still available, and what rules currently apply to visits?
- 03How are people and staff tested for infections now, and how are unclear or missing results followed up?
- 04How would the home separate and care for someone who developed an infectious illness?
- 05What were the home's ratings or findings in areas not covered by this targeted inspection, such as care, medicines, staffing and management?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic, so the service was inspected but not rated and other areas of care were not assessed. This explanation was written from the published report of 18 December 2020 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 Westgreen House
5 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- June 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- December 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- December 2014Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2020
Registered with the Care Quality Commission on 5 October 2020.
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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