Westgreen House

Updated 18 June 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Two inspectors and an Expert by Experience carried out this inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Westgreen House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Westgreen House is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed the information we had received since the care home registered with us under the new provider. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

We used all this information to plan our inspection.

During the inspection

We spoke with 10 people who used the service and 11 relatives to gain their view of the care and services provided. We spoke with six members of staff which included care staff, activities co-ordinator, two ancillary staff and a nurse. We also spoke with members of the management team which included the nominated individual.

The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed five people’s care records and a selection of medicine administration records. We reviewed records relating to the Mental Capacity Act and Deprivation of Liberty Safeguards.

We reviewed three staff recruitment files, support records and the care home’s training record. We also reviewed a selection of records relating to the management of the service which included quality monitoring audits, minutes of meetings and complaints and compliments records.

Updated 18 June 2022

About the service

Westgreen House is a residential care home providing nursing or personal care to up to 45 people. The service predominantly provides support to older people, of whom some live with dementia. At the time of inspection there were 32 people using the service.

People were accommodated in one adapted building across two floors. Part of the building was closed due to building work in progress. The care home was operating as three units, one of which provided support to people who required additional support to live with dementia.

People’s experience of using this service and what we found

Risks to people had not always been sufficiently assessed, planned and managed. Staff had not received sufficient or appropriate training, in line with best practice guidance, to safely support people with distressed behaviours. We made a recommendation to support the deployment of staff.

People did not always receive the care and support they required to meet their individual needs and preferences. People’s care plans did not always reflect their needs.

The provider had systems in place to protect people from the risk of abuse, however, one incident was not promptly notified to CQC to ensure all relevant agencies could monitor people’s safety. We made a recommendation to support external incident reporting.

The provider’s quality monitoring processes had not been effective in identifying shortfalls found during this inspection.

We made a recommendation about records relating to concerns and complaints.

We were not fully assured that people were supported to have maximum choice and control of their lives. Although staff were aiming to support people in the least restrictive way possible, practices and records showed that this had not always been the case and the principles of the MCA were not always followed. Decisions made on behalf of people and in their best interests were not always clearly recorded.

People and relatives told us the staff were caring, kind, friendly and welcoming. People had access to healthcare professionals when required.

Infection, prevention and control arrangements were in place to help prevent the spread of infection. There were no restrictions in relation to visiting.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The service was newly registered with us under the current provider on 10 October 2020 and this is the first rated inspection of the service.

Why we inspected

The inspection was prompted in part due to concerns received about the quality of care provided, staff training, infection control practices, medication practices, management of service user behaviours, restrictive practices and the management of the service. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, responsive and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

The overall rating for the service is requires improvement based on the findings of this inspection.

During this inspection action was taken to reduce risks associated with distressed behaviours.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to the safe care and treatment of people, personalised care delivery and the provider’s quality monitoring processes at this inspection.

We have made recommendations regarding staff deployment, external incident reporting and recording of concerns received.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.