CQC report explained · a nursing home
What the CQC found at Westholme Clinic Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found systems to protect people from abuse, enough staff, safe recruitment and safe medicines procedures. The home was clean and equipment and premises were checked.
- Effective?
- Good
- Staff were trained and supported, and people received help with food, drink and healthcare. However, some capacity and best-interests records were not complete.
- Caring?
- Good
- People and relatives described staff as kind, respectful and friendly. Inspectors observed compassionate care and support for dignity, choice and independence.
- Responsive?
- Good
- Care was personalised to people's needs, communication methods, interests and preferences. People were supported to maintain relationships, take part in activities and raise complaints.
- Well-led?
- Requires improvement
- The management team was open, caring and committed, but quality systems did not identify incomplete records or weaknesses in modified-diet assessments and best-interests decisions.
What inspectors found, November 2019
Rated Good overall, but well-led Requires Improvement because care records and dietary assessments were not always complete.
Inspectors made an unannounced visit on 10 October 2019. They spoke with people living in the home, visitors and staff. They observed care and checked care records, medicines records, staff files and management records.
The home was rated Good for safe, effective, caring and responsive care. People said they felt safe, had enough staff, and were treated kindly. Inspectors found personalised care, safe medicines practice, trained staff and good support with food, activities and healthcare.
The well-led rating was Requires Improvement. Some records were incomplete, including records about modified diets, nutrition and best-interests decisions. Inspectors found no evidence that people had been harmed, and the manager took immediate action after the inspection.
People felt safe
People and relatives told inspectors they felt safe. Staff understood how to recognise and report possible abuse.
“People and their relatives told us they felt safe.” from the report
Kind and respectful care
Inspectors saw warm, compassionate relationships. People were supported with dignity and encouraged to make choices and remain independent.
“People were treated with dignity and compassion by a kind, caring staff and management team who understood people's individual needs, choices and preferences well.” from the report
Enough trained staff
There were enough staff to provide care on time. Staff received induction, training and supervision, and people were supported by a consistent team who knew them well.
“There were enough staff on duty. People received care and support in a timely way” from the report
Personalised support
Staff adapted care to people's routines, communication needs, interests and preferences. Inspectors saw people being supported to enjoy activities and maintain skills.
“People experienced personalised care and support that promoted their physical and mental wellbeing and enhanced their quality of life.” from the report
Safe medicines practice
Nurses were trained and checked as competent to give medicines. Records and systems were audited, and medicines were given in line with people's preferences.
“People received their medicines safely from trained nurses” from the report
Incomplete care records
needs fixingSome records did not explain people's nutritional needs or how best-interests decisions had been made. This made it harder for the home to show that care was properly assessed and monitored.
“There was not an adequate process for ensuring some records were complete and up to date.” from the report
Modified diets
seriousRecords for people on modified diets did not explain why the diet was needed or show an appropriate specialist assessment. The home could not be sure the correct food consistency was being provided, creating a potential risk of significant harm.
“This meant the provider could not be assured correct consistency food was being served to people to reduce the risk of significant harm.” from the report
Capacity and consent records
needs fixingDecision-specific capacity assessments and best-interests records were not always completed. Some relatives were asked to consent without having the legal authority to do so.
“Processes had failed to identify some relatives being asked to consent on behalf of their loved one without having the legal power to do so.” from the report
- 01Have all people receiving a modified diet now had an assessment by a speech and language therapist?
- 02How are food textures recorded now, and how do you check that the correct consistency is served?
- 03How do you record decision-specific mental capacity assessments and best-interests decisions?
- 04How do you check that relatives asked to make decisions have the correct legal authority?
- 05What changes have been made to the quality checks since the inspection found incomplete records?
This was an unannounced inspection covering all five CQC questions, with the overall rating remaining Good but the well-led rating falling to Requires Improvement. This explanation was written from the published report of 26 November 2019 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 2017
Rated Good; inspectors found safe, kind and personalised care, with improvements since the previous inspection.
Inspectors visited the home without notice on 8 and 14 February 2017. They spoke with people, relatives, staff and a social worker. They observed care and reviewed care plans, medicines records, staff files, training records and management checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and were treated with kindness and respect. Inspectors found enough staff, safer medicines systems, suitable risk assessments and care plans that reflected people's needs and preferences.
The home had improved since the previous inspection, when it was rated Requires Improvement and had two breaches. The report says those regulations were now met. Activities included music, dancing, gardening and dementia-focused programmes, and people and relatives were asked for their views.
Safer medicines
The home had improved its medicines systems after the previous inspection. Records, storage, staff training and competency checks were in place.
“All staff who were authorised to administer medicines had received training and this included a competency assessment” from the report
Personalised care
Care plans contained detailed information about each person's needs, preferences, background and how staff should support them.
“Each person had a plan of care that identified their assessed support needs. Each care plan was individual to meet their specific care needs.” from the report
Kind and respectful staff
Inspectors saw staff communicate calmly and warmly with people. Staff respected privacy, dignity and people's choices.
“We saw people were treated with kindness and compassion and staff related to people in a courteous and friendly manner.” from the report
Activities and wellbeing
The home offered varied activities and had introduced dementia-focused programmes, including sensory and music sessions to support wellbeing.
“There was a range of other activities on offer for people. One person said "Oh there is plenty to do".” from the report
Open management
The manager welcomed feedback and carried out regular checks. People, relatives and staff were involved in meetings and improvement plans.
“The provider was proactive in making plans to improve the service and carried out regular audits of the service provision.” from the report
Inspectors raised no specific concerns in this report.
- 01How are medicines checked now, and how often are staff assessed as competent to administer them?
- 02How often will my relative's care plan be reviewed, and how will their family be involved?
- 03What is the current position with any DoLS applications or authorisations for my relative?
- 04Which activities would suit my relative's interests, dementia needs and personal preferences?
- 05How do you check that staffing levels are sufficient for people's needs on every shift?
This was an unannounced comprehensive inspection covering all five CQC questions; inspectors noted that not everyone could share their experience because some people were living with dementia. This explanation was written from the published report of 7 March 2017 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 Westholme Clinic Limited
4 rated inspections over 5 years: the service has improved, from Inadequate to Good.
- November 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2015Inspected but not ratedSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- April 2015InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- December 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 7 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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