CQC report explained · a residential care home
What the CQC found at Westlands Retirement Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that safeguarding systems were in place, risks were assessed and managed, staffing was sufficient at the inspection, and medicines were handled safely. Some people said they would like more staff, and an increase was planned.
- Effective?
- Good
- People's needs were assessed before admission. Staff received induction, training and supervision, and people were supported with nutrition, hydration, healthcare and decisions about their care.
- Caring?
- Good
- Inspectors observed kind, gentle and respectful care. Staff involved people in decisions, protected their privacy and supported their independence.
- Responsive?
- Good
- Care plans were personalised and reviewed monthly. The home provided activities, supported visitors, responded to complaints and planned for people's end-of-life wishes.
- Well-led?
- Good
- The new manager had introduced many changes and inspectors found a positive culture. The home gathered feedback, carried out audits and worked with health and social care services.
What inspectors found, August 2018
Rated Good; inspectors found safe, kind and personalised care, with staffing and refurbishment improvements still under way.
This was an unannounced inspection on 18 July 2018. Inspectors spoke with people living in the home, relatives, staff and health professionals. They reviewed care plans, recruitment files, supervision records, staffing rotas and management records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were protected from abuse, risks were managed, medicines were handled safely and there were enough staff at the time of the inspection.
People received care that reflected their needs and preferences. Staff supported people with food, drinks, healthcare, activities and end-of-life care. Inspectors observed kind and respectful interactions, and found that people and relatives were involved in care planning.
The report also records that the new manager had made many changes and that refurbishment was under way. Some people wanted more staff, and the home had planned to increase staffing from 23 July 2018.
Safe care
Staff understood how to recognise and report abuse. Risks such as falls, choking, poor nutrition and skin damage were assessed and managed.
“People were kept safe from the risk of abuse as staff had undertaken relevant training and understood their responsibilities to protect people.” from the report
Kind and respectful staff
Inspectors saw staff respond sensitively to people's moods and distress. People were treated with dignity and involved in everyday choices.
“Staff were observed to treat people with dignity and respect throughout the inspection.” from the report
Personalised support
Care plans included people's preferences, life histories, communication needs and wishes about how care should be given. Staff reviewed plans each month.
“People had personalised care plans that reflected them as an individual in terms of their care needs and preferences about how they wanted their care to be provided.” from the report
Activities and social life
People could choose from a range of daily activities, including music, games, exercise, gardening and baking. Visitors were allowed when people wished.
“People were provided with a range of activities to stimulate them.” from the report
Active management
The new manager had made many changes, including improvements to care plans, staffing arrangements and the environment. Audits were used to identify and act on improvements.
“Since their appointment they had documented a total of 73 changes or improvements to the service they had introduced.” from the report
Some people wanted more staff
needs fixingSome people said they would like to see more staff. The provider had identified this and planned to add one care worker during the day from 23 July 2018.
“Some people expressed the view they would like to have seen more staff, the provider had also identified this need, which they were addressing for people.” from the report
Refurbishment was incomplete
minorSome walls needed redecoration and carpets and other improvements were still being completed. Families may want to check what work has since been finished.
“Some walls required redecoration, and this was underway.” from the report
- 01Has the planned extra daytime care worker been added, and how do you decide whether staffing is enough for each shift?
- 02Which refurbishment work has been completed, including the carpets, lounges, signage and garden improvements?
- 03How will you assess and support my relative's risks, such as falls, choking, poor nutrition or skin damage?
- 04How will my relative and our family be involved in monthly care plan reviews?
- 05What activities and support would be available if my relative has dementia, communication difficulties or changing behaviour?
This was an unannounced inspection of the whole service, including care and the premises, and it assessed all five CQC questions; a previous focused inspection on 5 February 2018 had checked earlier breaches. This explanation was written from the published report of 2 August 2018 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 2018
Rated Requires Improvement; inspectors found important safety and management improvements, but some standards were not yet consistent.
Inspectors made an unannounced, focused inspection on 5 February 2018. They checked whether the home had acted on problems found in July 2017. They spoke with people, staff and professionals, and reviewed care, recruitment and management records.
The home had improved how it monitored people's fluids, managed medicines, checked equipment and responded to incidents. People were safeguarded from abuse, and there were enough staff to meet people's needs. However, some medicines were not dated when opened, some recruitment checks were incomplete, and parts of the home were not clean enough.
The new manager had made many changes and had improved links with health and social care professionals. However, audits did not yet show consistent improvement over time. The home remained Requires Improvement for Safe, Well-led and overall. The legal requirements breached at the previous inspection had been met, but the ratings had not yet improved because the changes were not fully embedded.
Better monitoring of fluids
People had individual fluid targets, and the home recorded intake for people at risk of dehydration. Staff made sure drinks were available and contacted GPs when there were concerns.
“Processes were in place to identify and take appropriate actions where people's fluid intake fell below their target.” from the report
Safer medicines systems
Staff had medicines training and competency checks. Ordering, storage and disposal systems were in place, and the pharmacist had no concerns about medicines management.
“Staff who administered medicines had received training and had their competency to do so assessed.” from the report
Learning from incidents
The home reviewed falls and other incidents, shared learning with staff and made changes intended to reduce the chance of repeat incidents.
“In the event of an incident or accident there was good evidence of lessons being learnt and processes being put in place in response.” from the report
Management changes
The new manager had made many service improvements and had strengthened working relationships with the GP practice, pharmacy and social services.
“The manager had since their appointment made 45 service improvements.” from the report
Medicines not always dated
needs fixingThree of six topical cream containers checked were not dated when opened. Thickeners also did not have opening dates recorded, and one soluble tablet was not fully dissolved before being given.
“Three of the six topical creams containers we checked were not dated with their date of opening to ensure they were used within a safe timeframe.” from the report
Cleaning standards
needs fixingSome areas cleaned by care staff were not clean enough. The home needed better systems to schedule and check cleaning, and was recruiting extra cleaning and maintenance staff.
“Infection control was an area that required improvement to ensure adequate cleaning of the service and sufficient oversight.” from the report
Incomplete recruitment checks
needs fixingSome information in staff files was missing or had not been independently verified. The home had accepted agency checks without carrying out all of its own checks.
“The provider had not followed good practice and reviewed the DBS certificate for themselves in order to check the applicant's identity and that the correct level of check had been completed.” from the report
Staff not always visible
seriousStaff were not always present in communal areas as set out in the home's falls guidance. Inspectors saw an altercation between two people while staff were absent.
“We noted that staff were not always present in the communal areas, as per the provider's aim stated in their falls guidance.” from the report
Audits not yet reliable
needs fixingThe home had introduced more audits, but some audits were not yet fully effective and did not show consistent improvements over time. Some observations and a verbal complaint were also not recorded properly.
“More time was needed for the provider to be able to demonstrate that audits had driven consistent improvements in the service over time.” from the report
- 01How do you now make sure every topical cream and thickener is dated when opened?
- 02What checks do you carry out on agency staff recruitment records, including DBS certificates?
- 03How do you ensure staff are present in communal areas at times when people may be at higher risk?
- 04How do you check that cleaning standards remain consistent on every shift?
- 05What evidence can you show that your audits have led to lasting improvements since this inspection?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 13 March 2018 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 Westlands Retirement Home
5 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- August 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2018Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- August 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- August 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- March 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- July 2012
Registered with the Care Quality Commission on 4 July 2012.
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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