CQC report explained · a residential care home
What the CQC found at Westleigh
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risk assessments and monitoring were incomplete, and not all environmental safety checks were carried out regularly. Medicines were stored safely and staff were trained, but some medicines processes needed improvement.
- Effective?
- Good
- People received support based on their needs and choices. Staff had training, supervision and appraisals, and people were supported with healthcare, nutrition and hydration.
- Caring?
- Good
- Inspectors observed kind, compassionate, respectful care. People were involved in decisions and encouraged to remain as independent as possible.
- Responsive?
- Good
- Care was personalised and activities reflected people's interests. Complaints information was provided and the complaints process was managed in line with policy, although no complaints had been submitted at the time.
- Well-led?
- Requires improvement
- Quality checks and audits did not reliably identify problems with risks, restrictions or safety checks. The manager responded to the inspectors' feedback and had a service improvement plan.
What inspectors found, September 2019
Westleigh was rated Requires Improvement; inspectors found kind, responsive care but weaknesses in safety records, medicines and management oversight.
Inspectors made an unannounced visit on 12 August 2019. They spoke with nine people living at the home, staff and the manager. They reviewed care records, recruitment files, medicines records and management documents, and observed care.
People were generally treated kindly and with respect. Inspectors found good support with people's health, food, activities, communication and personal choices. Staffing levels and recruitment were appropriate, and staff understood the people they supported.
However, some risks were not properly recorded or checked. Inspectors also found problems with some medicines processes and safety checks. The systems intended to find these problems were not effective enough. The overall rating changed from Good at the previous inspection to Requires Improvement, with breaches of regulations on safe care and treatment and good governance.
Kind and respectful care
People told inspectors that staff were kind and helpful. Inspectors observed respectful care and staff knew people's preferences.
“People told us they received kind and compassionate care by the staff who worked at Westleigh.” from the report
Suitable staffing and recruitment
Staffing levels were assessed against people's support needs. Recruitment checks, including DBS checks, had been completed.
“Staff were safely recruited; staff were subject to the necessary pre-employment and Disclosure and Barring System (DBS) checks.” from the report
Staff training and medicines support
Staff received training, supervision and appraisals. Staff who supported people with medicines were trained and had their competence checked.
“People received support with their medicines by trained members of staff; staff also had their competency levels regularly checked.” from the report
Activities matched people's interests
The activities programme included group and individual activities. Inspectors found that activities were based on people's likes and interests.
“An activities co-ordinator helped provide a range of different group and one to one activities for people living at Westleigh.” from the report
Risk records and monitoring
seriousSome relevant risk assessments and support plans were missing. Risks were not always checked as often as needed, including daily skin checks for one person.
“People's support needs and level of risk were assessed from the outset, however, we found that not all relevant risk assessments were in place.” from the report
Medicines processes
needs fixingMedicine temperature checks were not completed often enough, and inspectors found concerns about ordering and supply. CQC recommended that the provider review its medicines processes.
“Medication temperature checks were not completed as regularly as they should have been, and we identified some concerns with the ordering and supply of medicines.” from the report
Weak management checks
seriousAudits and quality checks did not identify problems that inspectors found in care records, restrictions and environmental safety checks.
“Quality assurance systems were in place; however, these were not always effective.” from the report
Restrictions not reviewed often enough
needs fixingOne person's specific restrictions were not reviewed as regularly as they should have been. The manager was responsive when inspectors raised this.
“one person's specific restrictions were not reviewed as regularly as they should've have been.” from the report
- 01What has been done to make sure every person's risk assessment and support plan is complete and regularly reviewed?
- 02How are daily skin checks and other individual risk monitoring recorded and checked by managers?
- 03What changes have been made to medicine temperature checks, ordering and supply?
- 04How are safety checks, care record audits and restrictions now monitored so that problems are identified promptly?
- 05What progress has been made on the action plan requested by CQC?
This was a planned, unannounced inspection covering all five CQC questions, including the premises and care provided; the report says the previous overall rating was Good and the new ratings were based on this inspection. This explanation was written from the published report of 11 September 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
Westleigh is rated Good; inspectors found safe, respectful and personalised care, with some privacy and fire-safety points to check.
This was an unannounced inspection on 21 February 2017. One inspector and an expert by experience spoke with 12 people, four staff and the registered manager. They observed care and checked care records, medicines, staff files, rotas and quality checks.
The overall rating was Good. Safe, Effective, Caring, Responsive and Well-led were all rated Good. People told inspectors they felt safe, were treated with respect, and could make choices about their care and daily life.
The home had improved since the October 2015 inspection. Care records and risk assessments were now up to date and detailed. The provider had also put better monitoring and medicines audit systems in place, so the previous breaches were no longer ongoing.
Inspectors noted that visitors sometimes entered without waiting for staff, which could affect privacy. They also found that extra smoke detectors were being arranged for bedrooms where people sometimes smoked.
Up-to-date care planning
Care plans and risk assessments were clear, detailed and based on people's current needs. People were involved in planning their care where they could be.
“The care plans and risk assessments we saw were clear, concise and comprehensive and informed staff how to best meet people's individual needs.” from the report
People felt safe
Staff knew how to recognise and report possible abuse. They understood people's risks and followed plans to reduce harm.
“Risks of harm to people were assessed and minimised through the staff knowledge of people's risks and the effective use of risk assessments.” from the report
Respect and independence
People were supported to make their own choices, use the home freely and take part in activities in the home and community.
“We saw that people were encouraged to be as independent as possible.” from the report
Improved management checks
The provider had acted on the previous inspection findings. Regular service and medicines audits were now being completed.
“The registered manager was now using the provider's monthly audit tool to monitor and improve the service.” from the report
Visitor access and privacy
minorInspectors saw visitors entering without ringing the bell and waiting. The manager said a sign would be put up asking visitors to wait to be let in.
“Visitors often entered the building without ringing the bell and waiting and this could compromise people's right to privacy.” from the report
Smoke alarm arrangements
needs fixingSome people sometimes smoked in their bedrooms. Appropriate smoke detectors linked to the home's fire alarm were being arranged, but this was not yet complete on the inspection day.
“The detectors in place only detected heat and not smoke.” from the report
- 01Have the appropriate smoke detectors been fitted in the bedrooms where people may smoke, and are they linked to the home's fire alarm?
- 02What arrangements are now in place to ensure visitors ring the bell and wait before entering?
- 03How often are care plans and risk assessments reviewed when a person's needs change?
- 04How are medicines audits and other quality checks acted on when they identify a problem?
- 05How do you make sure staffing levels and flexible shifts still support health appointments, activities and people's changing needs?
This was an unannounced inspection covering the overall quality of the home and all five key questions; the report also checked progress against concerns found at the October 2015 inspection. This explanation was written from the published report of 1 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 Westleigh
3 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- September 2019Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2014
Registered with the Care Quality Commission on 11 April 2014.
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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