CQC report explained · a residential care home
What the CQC found at Westy Hall Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about infection prevention measures, including visitors, protective equipment, testing, vaccinations and outbreak management. Some improvements were needed to environmental and equipment cleanliness, and cleaning records.
- Effective?
- Good
- This question was not assessed in this targeted inspection.
- Caring?
- Good
- This question was not assessed in this targeted inspection.
- Responsive?
- Requires improvement
- This question was not assessed in this targeted inspection.
- Well-led?
- Good
- This question was not assessed in this targeted inspection.
What inspectors found, February 2022
Inspected but not rated; inspectors were assured about infection control, but some cleaning records and cleanliness needed improvement.
This was an announced, targeted inspection on 28 January 2022. It checked infection prevention and control during the COVID-19 response, and asked about staffing pressures.
Inspectors were assured that the home was managing visitors, social distancing, protective equipment, testing, vaccinations and infection outbreaks in line with guidance. Staff were observed using and disposing of protective equipment correctly.
Families were kept informed, and people were supported to stay in contact with relatives through visits and other communication. However, inspectors found that some parts of the environment and mobility equipment needed better cleaning, and cleaning tasks were not always recorded.
The home was inspected but not rated. This means this report does not give an overall quality rating or ratings for the other care questions.
Infection control
Inspectors were assured that the home had measures to reduce the risk of infections spreading. Staff had infection prevention training and were observed using protective equipment correctly.
“We were assured that the provider was using PPE effectively and safely.” from the report
Family communication
The home regularly updated relatives about important changes, particularly during the COVID-19 response. People were supported to maintain contact with family members.
“The registered manager and staff regularly communicated with family members to keep them informed of any important changes” from the report
Testing and vaccination
People and staff were supported to access regular COVID-19 testing. The home was meeting the vaccination requirement for non-exempt staff and visiting professionals.
“The service was meeting the requirement to ensure non-exempt staff and visiting professionals were vaccinated against COVID-19.” from the report
Cleaning records and equipment
needs fixingSome areas of the environment and equipment used for mobility needed better cleaning. Cleaning schedules existed, but not every cleaning task was recorded.
“Some improvements were needed to the overall cleanliness of the environment and equipment used to support people with their mobility.” from the report
- 01What improvements have been made to the cleanliness of the environment and mobility equipment since the inspection?
- 02How do you now make sure every cleaning task is recorded?
- 03How are current staffing pressures affecting people's care and daily routines?
- 04How are visitors, staff and professionals currently tested and checked under your infection control arrangements?
- 05What quality ratings should families use alongside this targeted report when assessing the home?
This was a targeted inspection of infection prevention and control and staffing pressures; it was not a full service assessment and the home was inspected but not rated. This explanation was written from the published report of 10 February 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, August 2019
Westy Hall Residential Care Home was rated Good overall, but inspectors found activities and some complaint records needed improvement.
This was an unannounced inspection on 11 and 19 July 2019. Inspectors reviewed records, medicines and recruitment files, observed care, and spoke with people living at the home, relatives, staff and managers.
The home was rated Good for Safe, Effective, Caring and Well-led. Inspectors found kind interactions, safe medicines management, suitable training, personalised care plans, good links with health professionals and effective checks on quality and safety.
Responsive was rated Requires Improvement. People wanted more regular activities, particularly activities suitable for people living with dementia. Some complaint records did not clearly show how concerns had been investigated or resolved.
The overall rating improved from Requires Improvement at the previous inspection. The two earlier breaches about premises and equipment and good governance had been addressed, and there were no breaches at this inspection.
Kind and respectful care
Inspectors observed compassionate interactions and found that staff knew people well. People and relatives were positive about how staff treated them.
“We observed staff speaking to people with kindness and respect throughout the inspection.” from the report
Safe medicines
Medicines records were accurate and regularly checked. Staff who supported people with medicines had suitable training and updates.
“Medication was managed safely. Records were accurately maintained and subject to regular audits by senior staff to check safe practices were maintained.” from the report
Personalised support
Care plans recorded people's needs, likes, dislikes and wishes. Staff were familiar with people's individual support needs.
“Care plans contained information that had been developed to offer person-centred care which focused on each person's preferences, their likes, dislikes and wishes.” from the report
Improvement since the last inspection
The home had addressed the two previous regulatory breaches. Its Effective and Well-led ratings improved to Good.
“At this inspection improvements had been made and the provider was not in breach of regulations.” from the report
Not enough regular activities
needs fixingPeople said they wanted more activities each day. Inspectors recommended developing activities for people with dementia and cognitive conditions.
“People using the service expressed mixed feedback regarding the activities on offer and told us that they would like access to more activities” from the report
Some complaint records were incomplete
needs fixingSome records did not clearly show the investigation or action taken. The manager revised the recording process after the inspection.
“One record had limited information and didn't fully reflect the actions taken to address the concerns.” from the report
Some areas needed refurbishment
minorInspectors found signs of wear and tear, including a stained and scraped sink surround and a mattress that needed replacing. A programme of maintenance and redecoration was in place.
“However, some rooms were quite bare in comparison and some in need of refurbishment.” from the report
- 01What activities are now available each day, and how are they adapted for people living with dementia or cognitive conditions?
- 02How do you record, investigate and follow up complaints so that the action taken is clear?
- 03What maintenance and refurbishment work remains, and when will it be completed?
- 04How do you maintain staffing levels when someone is off sick?
- 05How are people's preferences recorded and checked as their needs change?
This was an unannounced planned inspection based on the previous rating and covered all five CQC questions, including the care and the premises. This explanation was written from the published report of 8 August 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 Westy Hall Residential Care Home
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at Westy Hall Residential Care Home →
- August 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
Read what inspectors found at Westy Hall Residential Care Home →
- August 2018Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2016
Registered with the Care Quality Commission on 8 November 2016.
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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