CQC report explained · a residential care home
What the CQC found at Westmead
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found medicine errors, unclear records and weaknesses in staff medicine competency checks. Some risk assessments were not detailed enough, although staff understood safeguarding and there were enough staff with suitable skills for current needs.
- Effective?
- Good
- People had detailed care plans, staff understood their needs and choices, and health needs were well managed with support from healthcare professionals. The building supported physical disabilities, although it was not in line with best practice for people with learning disabilities.
- Caring?
- Good
- Staff had caring relationships with people and respected their choices, privacy, dignity and independence. One incident where a person was left uncovered was raised with managers and said to have been addressed.
- Responsive?
- Requires improvement
- People's communication needs and daily preferences were understood, but opportunities for outings, activities and use of different rooms were limited. The home said it would offer more outings and record them.
- Well-led?
- Requires improvement
- Managers were caring and understood their responsibilities, but quality systems had not identified medicine, activity, lighting and infection-control issues. The home sent action plans after the inspection.
What inspectors found, January 2022
Rated Requires Improvement; inspectors found kind, effective care but medicines, activities and quality checks needed improvement.
Inspectors visited on 20 and 24 November and 13 December 2021. The first visit was unannounced and the later visit was announced. They spoke with people, staff, relatives and professionals, observed care and checked care, medicine, staff and management records.
Most people felt safe and well cared for. Staff knew people's needs and wishes, treated them kindly and supported their health, food, communication and independence. The effective and caring parts of the service were rated Good.
There were important weaknesses. Medicines had not always been given or recorded safely, some risk assessments lacked detail, and people did not always have enough opportunities to go out or use different areas of the home. The quality checks had not found these problems. The home took action after the inspection, but the safe, responsive and well-led ratings were Requires Improvement.
Kind relationships
People and relatives described staff as kind and supportive. Inspectors saw staff treating people as individuals and respecting their communication needs.
“It was clear from our observations that staff had very caring relationships with people.” from the report
Personalised care
Care plans recorded people's routines, preferences and support needs. Staff could explain how to offer choice while keeping people safe.
“People had detailed individualised assessments, care plans and some risk assessments in line with best practice guidance.” from the report
Suitable staffing
Inspectors found enough staff with the right skills and experience for people's current needs. Recruitment checks were completed before new staff started work.
“There were enough staff with the right skills and experience to meet the current needs of people using the service.” from the report
Health support
Staff worked with healthcare professionals and supported people with complex health needs. Meals were adapted where there was a choking risk.
“People's healthcare needs were well managed. This was because the staff team worked closely with healthcare professionals to ensure good outcomes.” from the report
Medicine safety
seriousThere had been many medicine errors, including unclear controlled-drug records and inconsistent liquid pain-medicine doses. CQC found no evidence of harm, but said people were at potential risk.
“There had been a large number of errors and not all had been fully investigated.” from the report
Quality checks
seriousThe home's audits had not identified several problems found by inspectors, including medicine errors and limited activities. This was a breach of the good-governance regulation.
“Some of the quality audits had failed to identify the areas of concern we identified during this inspection.” from the report
Limited activities and outings
needs fixingPeople were not always supported to go out, use quieter areas or take part in meaningful activities. The home said it had started offering more outings after the inspection.
“Given COVID-19 measures and being cautious staff could have still supported people to go for a walk or drive to a local place of interest.” from the report
Incomplete risk information
needs fixingSome health risk assessments, including for stoma and catheter care, did not give staff enough detail. The manager and staff updated them after inspectors raised the issue.
“People's health care risk assessments were not detailed enough to ensure staff had the right information to mitigate all risks.” from the report
- 01What changes have been made to medicine administration, controlled-drug records and staff competency checks since this inspection?
- 02How are medicine errors now investigated, recorded and reviewed by managers?
- 03How often can residents go out, including at weekends, and how are these opportunities recorded?
- 04How are the sensory room, upstairs lounge and computer suite now being used to offer quieter spaces and activities?
- 05How are care plans and risk assessments for stoma, catheter and other complex care needs checked for detail and accuracy?
This was a planned inspection covering all five key questions, including infection prevention and control; it was the first inspection under the new provider, and the previous Good rating was under the former provider. This explanation was written from the published report of 18 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.
What inspectors found, February 2021
Westmead was inspected but not rated; inspectors were assured about infection prevention and control during the coronavirus pandemic.
This was an announced, targeted inspection on 11 February 2021. It checked how the home was preventing and managing infections linked to COVID-19.
Inspectors were assured that the home used protective equipment safely, arranged testing, followed visiting and social distancing rules, and had plans for safe admissions and outbreaks. The home was clean, with regular cleaning of frequently touched areas.
The home had created a separate visiting pod so families could visit without entering the main building. Most people and staff had received the coronavirus vaccination.
The service was inspected but not rated. This means the report gives findings about infection control, rather than an overall quality rating.
Family visits
The home adapted a spare bedroom into a separate visiting pod. This allowed visits while keeping visitors out of the main building.
“The provider had adapted one spare bedroom as a visiting pod to enable people to still have visits with their family in a safe and protected way.” from the report
Protective equipment
Inspectors saw staff using suitable PPE. Staff had received training on putting it on and taking it off safely.
“Safe procedures have been followed by staff to minimise the risk of transmitting Covid-19.” from the report
Testing and isolation
Regular testing was in place for people living at the home and staff. People who tested positive isolated for the required period.
“Measures were in place to ensure staff and people living at the service had regular testing.” from the report
Cleaning
The home had cleaning schedules and frequent cleaning of high-touch areas, with deep cleaning at least monthly.
“Detailed cleaning schedules were in place for all areas of the home.” from the report
Inspectors raised no specific concerns in this report.
- 01Are visits still held in a separate visiting pod, and what arrangements are now available for family visits?
- 02How are people and staff tested if there is a suspected or confirmed COVID-19 case?
- 03What happens if someone living at the home tests positive, including how isolation affects their care and contact with family?
- 04How often are high-touch areas and communal spaces cleaned now?
- 05What infection control training have staff received since this inspection?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; it was not a full service rating. This explanation was written from the published report of 26 February 2021 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 Westmead
6 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- January 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- July 2018Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2017Requires improvementstayed Requires improvementSafe: Good
- June 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2015Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2014Inspected but not rated
- August 2019
Registered with the Care Quality Commission on 6 August 2019.
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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Most charge £1,020 to £1,270 a week. 15 can care for a couple. 13 years' experience on average.
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