Archived: Signature at Westbourne

Updated 22 February 2023

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.

Inspection team

The inspection was carried out by 2 inspectors and a pharmacist specialist.

Service and service type

Signature at Westbourne 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. Signature at Westbourne 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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

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 information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 15 people who used the service and 11 relatives about their experience of the care provided. We spoke with 23 members of staff including the nominated individual, regional operations director, regional operations clinical lead, head of governance, registered manager, deputy manager, care staff and catering staff.

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

We also spoke to 5 health and social care professional who had experience of the service. We observed care to help us understand the experience of people who could not talk with us. We reviewed a range of records. This included 9 people's care records and multiple medication records. We looked at 3 staff files in relation to recruitment and staff supervision and a variety of records relating to the management of the service.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Updated 22 February 2023

About the service

Signature at Westbourne is a nursing home providing personal care and nursing care to 108 people at the time of the inspection. The service can support up to 114 people. Signature at Westbourne is a purpose-built building and is accessed over four floors by stairs or a lift. People could access the ground and first floors freely, the second and third floor had restricted access to keep people living with dementia safe.

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

People told us they felt safe and were happy living at Signature at Westbourne. Comments included, “this is my home now and I am very happy”, “the staff are lovely” and, “this is the perfect place for me.”

The design and decoration of the premises did not always follow the best practice guidance for supporting people living with dementia. Plans were in place to redecorate these areas. We have recommended the provider consults good practice guidance around providing a dementia friendly environment for people who use the service.

Peoples needs were assessed before they moved into the service. We found people’s protected characteristics had not always been considered as fully as they could have been. A new electronic care planning system was being introduced that included a more robust system for seeking protected characteristics. We recommended the provide consults good practice guidance to ensure assessments fully explored people’s needs to ensure they could be met before they moved into the service.

Staff had assessed people for risks to their health and well-being and created plan to minimise the likelihood of harm occurring. Clinical and non-clinical risks were discussed daily between staff to ensure people were safe. People told us there was enough staff to meet their needs. Staff had been recruited safely into the service and had received a comprehensive induction followed by regular training to ensure they had the right skills to meet people’s needs. Medicines had been managed safely and people were protected from the spread of infections. Lessons were learned when things went wrong.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff worked effectively with other agencies to provide consistent, effective and timely care. Staff supported people to access healthcare when required. People were supported to eat a well-balanced diet. Staff told us they felt supported to carry out their job roles.

People told us they were cared for by staff who knew their needs, were kind, respectful and treated them with dignity. One relative said, “[Person] settled in the home immediately which suggests that they must be doing something right.”

Staff provided people with care responsive to their needs. We identified one person was not always being supported to communicate as fully as they could have been. We brought this to the attention of the registered manager and provider who responded quickly and by the next day of our inspection we observed the way the person chose to communicate had been fully supported. This resulted in the person being able to tell staff their likes, dislikes and wishes.

There was a large activities programme in place, one person told us, “the programme of activities is brilliant.” The activity staff told us the plans they had to improve activities for people living with dementia and people who preferred a 1:1 activity.

People knew how to complain and felt they would be listened to. People were supported to have a dignified and respectful end of life when the time came.

People, relatives and staff spoke positively about the registered manager and management team. People and staff felt comfortable to speak open and honestly and felt they would be listened to. Quality assurance systems were in place to monitor the quality of the service and identify areas of improvement. Signature at Westbourne engaged with people, the public and staff to improve the running of the service.

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

Rating at last inspection

This service was registered with us on 10 December 2021 and this is the first inspection.

The last rating for the service under the previous provider was Outstanding, published on 2 February 2019.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.