18 May 2022
During an inspection looking at part of 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.