CQC report explained · a nursing home
What the CQC found at Westvilla Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- People received prescribed medicines on time, but instructions and records for medicines given only when needed were not always clear. Storage in bathrooms and communal areas also made some cleaning difficult.
- Effective?
- Good
- People's needs and choices were assessed, staff were trained and supported, and people received suitable food and healthcare. Improvements had also been made to fire safety.
- Caring?
- Good
- This key question was not assessed during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This key question was not assessed during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Good
- People and relatives were involved in care planning. The home had regular audits, meetings and systems for acting on incidents and improving care.
What inspectors found, July 2021
Rated Good overall; inspectors found good care and leadership but medicines records and some storage arrangements needed improvement.
This was an unannounced focused inspection on 25 May and 9 June 2021. Two inspectors spoke with people, staff and relatives, observed care, and checked medicines, care records, staff files, training, rotas and quality checks.
The home was rated Good overall. Effective and Well-led were rated Good. Safe was rated Requires Improvement because some medicines records were unclear and some storage arrangements made cleaning difficult.
People said they felt safe and well cared for. Staff were available, trained and recruited safely. The home had improved since the previous inspection in 2019 and was no longer in breach of regulations.
Staff availability
People said staff responded quickly when they needed help. Inspectors' observations supported this.
“There are always staff around, I call for them and they are always here quickly” from the report
Person-centred support
People and relatives were involved in care planning. Their individual needs, wishes, religion and sexuality were recorded and respected.
“People's diverse needs were respected and protected.” from the report
Improved fire safety
The home had made changes to the premises and had regular fire evacuation practice and training.
“The provider had carried out works to ensure the premises had been adapted to improve the fire safety of the premises.” from the report
Learning from incidents
The management team reviewed incidents, shared learning with staff and sought extra training after a medicines incident.
“Incidents and accidents were shared in team meetings in order to share learning and reduce the risk of reoccurrence.” from the report
Medicines records
seriousInstructions for some medicines given only when needed did not clearly say when or why they should be given. Some changes to medicine records had not been signed by two staff members.
“Not all people had protocols in place for medicines that were required as needed.” from the report
Storage and cleaning
needs fixingBathrooms and communal areas were being used for storage. This made some areas difficult to clean, although the home had an action plan and was taking steps to address the problem.
“There were storage issues within the home which resulted in bathrooms and communal areas being used as storage locations.” from the report
- 01Have all protocols for medicines given only when needed now been rewritten with clear instructions about when and why they should be given?
- 02How does the home check that handwritten medicine records and changes are signed by two staff members?
- 03Has the storage action plan been completed, including removing storage from bathrooms and communal areas?
- 04What are the current ratings for Caring and Responsive, which were not assessed in this inspection?
- 05How does the home check that infection control improvements remain effective?
This was a focused inspection of Safe, Effective and Well-led, including infection prevention and control; Caring and Responsive were not assessed and their previous ratings were carried forward. This explanation was written from the published report of 15 July 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.
What inspectors found, October 2019
Westvilla Nursing Home was rated Requires Improvement; inspectors found kind, responsive care but fire safety, infection control and quality checks were not reliable enough.
This was an unannounced inspection on 13 September 2019. One inspector spoke with three people, one relative and staff. They reviewed care, medicines, recruitment, training, complaints, fire safety and management records.
People were generally treated kindly and with respect. Staff supported people's health, nutrition, activities, choices and relationships. Medicines were managed safely, staffing levels were suitable, and people said they felt able to raise concerns.
The inspection found important safety problems. Three staff had not completed fire training requested after an earlier fire service visit. There were gaps in two laundry cupboard ceilings, and infection control in the laundry and sluices needed improvement.
The overall rating was Requires Improvement. Safe, Effective and Well-led were each rated Requires Improvement, while Caring and Responsive were rated Good. The previous overall rating had been Good.
Kind and respectful care
People described staff as compassionate, kind and attentive. Inspectors found that staff protected people's dignity and supported their independence.
“People told us the staff were compassionate and kind.” from the report
Personalised support
Care records included people's likes, dislikes, communication needs and preferences. Staff reviewed care plans and involved people, relatives and healthcare professionals.
“People received individualised care and support from staff.” from the report
Healthcare support
Staff worked with healthcare professionals and acted on advice about people's wellbeing. A healthcare professional said referrals were timely.
“Staff refer people timely to us and follow our advice.” from the report
Activities and relationships
The home provided activities linked to people's interests and encouraged contact with family and friends.
“Staff encouraged people to maintain and develop their contact and relationships with family and friends to avoid social isolation.” from the report
Fire safety
seriousThree staff had not completed fire training requested after an earlier fire service visit. Gaps in two laundry cupboard ceilings may have compromised fire safety.
“We found fire training had not been undertaken by three staff during the inspection.” from the report
Infection control
seriousThe laundry needed better cleaning and maintenance. Damaged shelving in the sluices created a risk of cross-contamination, and some equipment needed replacing.
“There was a cross contamination risk in the sluices.” from the report
Quality checks
needs fixingAudits had not found the fire safety and infection control problems. Inspectors asked the provider to improve monitoring and act more quickly when issues were found.
“However, these had not been effective in finding the shortfalls we found during the inspection.” from the report
- 01Have all staff now completed the fire training requested by Nottinghamshire Fire and Rescue Service?
- 02Have the gaps in the two laundry cupboard ceilings been repaired and checked as safe?
- 03What changes have been made to cleaning schedules and infection control in the laundry and sluices?
- 04How does the home now check that audits identify safety and infection control problems promptly?
- 05What progress has been made on the action plan following the two Requirement Notices?
This was an unannounced planned inspection of the care, premises and management of the home, and it rated all five CQC questions. This explanation was written from the published report of 22 October 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.
Every inspection of Westvilla Nursing Home
4 rated inspections over 6 years: the service has held its Good rating throughout.
- July 2021Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- February 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 8 February 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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