CQC report explained · a nursing home
What the CQC found at Westin Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2022
Rated Requires Improvement; inspectors found infection-control, risk and oversight problems, although staffing and interactions were positive.
The inspection took place on 28 and 29 March 2022. It was prompted partly by concerns about pressure-ulcer management and also looked at infection prevention and control during a COVID-19 outbreak. Inspectors spoke with people, staff, relatives and a physiotherapist, and reviewed care plans, recruitment files and policies.
The home was not always safe. Inspectors found poor infection-control practice, missing or inconsistent risk assessments, incorrectly set specialist mattresses, unsafe arrangements for checking bath and shower temperatures, and gaps in medicines and cream records. These problems increased the risk of avoidable harm.
The home was not always well-led. Checks and audits had missed important problems, and the registered manager was not involved in the home's day-to-day running. There were enough suitably qualified staff, people were protected from abuse, and inspectors saw kind and caring interactions.
The overall rating changed from Good at the previous inspection, published in January 2022, to Requires Improvement. Only Safe and Well-led were inspected at this visit. The other ratings carried over from the previous inspection.
Enough staff
Inspectors found enough suitably qualified staff to meet people's needs. Recruitment checks were also in place.
“There were sufficient numbers of suitably qualified staff to meet peoples' needs, and employment checks were in place to prevent unsuitable staff working in the service.” from the report
Kind interactions
Inspectors saw caring, person-centred interactions. People and relatives also gave positive comments about staff.
“Staff spoke about people in a person-centred way, we observed kind and caring interactions between people and staff.” from the report
Safeguarding response
Staff understood how to recognise and report abuse. Safeguarding concerns were referred to the local authority when needed.
“People were protected from the risk of abuse. Staff spoke confidently about how they would identify abuse and what actions they would take if abuse was suspected.” from the report
Infection-control failures
seriousThe home was experiencing a COVID-19 outbreak, but inspectors found waste in communal and private toilets, a visibly unclean and cluttered laundry area, and a used test strip by the laundry sink.
“The provider failed to implement a robust approach to infection prevention and control (IPC) practice.” from the report
Risk management gaps
seriousSome people's fire risk assessments were missing. Four of six specialist mattresses checked had incorrect weight settings, which could affect pressure-ulcer prevention.
“We reviewed settings on six mattresses, and found four were incorrect.” from the report
Medicines records
seriousThe home was not recording medicines-fridge temperatures properly. Records also did not always show that as-required medicines and topical creams had been given according to people's assessed needs.
“The provider could not always be assured that 'as required' (PRN) medicines, and topical creams, were being administered in line with peoples' assessed needs.” from the report
Weak oversight
seriousAudits did not identify the problems found by inspectors. The registered manager was not involved in the day-to-day running or in monitoring the quality and safety of care.
“Checks and audits had not always been used effectively and had failed to identify the concerns, errors and omissions we found during our inspection.” from the report
- 01What has been changed to prevent another infection-control failure, and how are cleanliness and waste removal now checked?
- 02How do you make sure every resident has a current fire risk assessment and that their risk guidance is followed?
- 03How are specialist mattress settings checked and recorded for each resident?
- 04How are medicines-fridge temperatures, as-required medicines and topical creams now monitored?
- 05Who is currently responsible for the home's day-to-day management, and how does the provider check that improvements are being sustained?
This was a focused inspection of Safe and Well-led; the other key-question ratings carried over from the previous inspection. This explanation was written from the published report of 7 May 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, January 2022
Rated Good; inspectors found safe, kind and personalised care, with some concerns about safeguarding history, complaints and mealtime noise.
This was the first inspection since the home was registered. It was unannounced and took place on 9 and 13 December 2021. Inspectors spoke with people, relatives, staff and health professionals. They also observed care and checked care records, staff files, policies and other records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough trained staff, safe medicines systems, good infection control and care plans that reflected people's needs. People said staff were kind and caring, and inspectors observed positive interactions.
The inspection was prompted partly by safeguarding concerns about personal care and medicines. Seven safeguarding concerns had been raised in the previous 12 months, but the management team had worked with the local authority to investigate them and take action. There had also been one medicines error, which was investigated and led to stronger procedures.
The home was asked to review television and music during meals in the main dining rooms. Inspectors also noted that one complainant felt their complaint had not been handled correctly. The report says the service will continue to be monitored and inspected again through the CQC's inspection programme or sooner if needed.
Enough trained staff
Inspectors found enough skilled and experienced staff to meet people's care needs. Recruitment checks were also in place.
“There were enough skilled and experienced staff to meet the care and support requirements of each person.” from the report
Kind and respectful care
People described staff as kind and patient. Inspectors observed positive interactions and found that personal care was delivered privately.
“They are very kind to me and quite patient” from the report
Personalised support
Care plans recorded people's preferences and needs, and were amended when circumstances changed. People and families were involved where appropriate.
“People were provided with person-centred care and support.” from the report
Learning from incidents
The service investigated safeguarding concerns, complaints and incidents, and made changes such as improving handovers and medicines procedures.
“The service had used the findings from complaints and safeguarding concerns to make improvements, using the learning as a positive outcome.” from the report
Safeguarding history
needs fixingSeven safeguarding concerns had been raised in the previous 12 months. The report says these were investigated with the local authority and actions were taken, but families should ask what safeguards are now in place.
“Seven safeguarding concerns had been raised in the previous 12 months, the last one being in September 2021.” from the report
Previous medicines error
needs fixingThere had been one medicines error in the previous year. It was investigated and procedures were strengthened after different instructions were found on the medicine box and hospital discharge letter.
“There had been one medicine error in the last 12 months, and this was investigated.” from the report
Mealtime noise
minorInspectors said the television and music made the meal experience less suitable in the larger dining room. They recommended reviewing how these are used during meals.
“The meal-time experience could have been improved if the television had been switched off or the volume reduced.” from the report
Manager registration
minorA new manager had been appointed but was not registered with the CQC at the time of inspection. The manager said an application would be made.
“The service did not have a manager registered with the Care Quality Commission.” from the report
- 01What changes were made after the seven safeguarding concerns, and how do you check that those changes are working?
- 02What was learned from the medicines error, and how are conflicting instructions from medicine packaging and hospital discharge letters now checked?
- 03What will you do to reduce television and music noise during meals in the larger dining room?
- 04What is the progress of the manager's application to register with the CQC?
- 05How are complaints now investigated, recorded and checked when someone feels their complaint was not handled correctly?
This was the first comprehensive, unannounced inspection since registration and covered all five key questions, including the premises, care, staffing, medicines, safeguarding and management. This explanation was written from the published report of 26 January 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 Westin Care Home
2 rated inspections over a year: the service has slipped, from Good to Requires improvement.
- May 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2022GoodSafe: GoodWell-led: Good
- October 2020
Registered with the Care Quality Commission on 8 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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