Westbourne Care Home

Updated 26 October 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

The inspection was carried out by one inspector.

Service and service type

Westbourne Care Home 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. Westbourne Care Home is a care home without 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 manager in post who was planning to apply to register with us.

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 a health and social care providers. 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 visited the service location on 29 September 2022 and had a video call with the manager on 6 October 2022. We spoke with five people and had feedback from six relatives. We also spoke with six staff including the manager, ancillary staff and support workers. We received feedback from health and social care professionals.

We reviewed a range of records. This included five people’s care records and medication records. A variety of records relating to the management of the service were also reviewed. These included training records, incident records and quality assurance processes.

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 26 October 2022

About the service

Westbourne Care Home is a residential care home providing personal to up to 27 people. The service provides support to older people, some of whom are living with dementia, in one adapted building. At the time of our inspection there were 23 people using the service.

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

People were supported safely and told us they felt safe. More robust documenting of risk management was needed to ensure staff had clear information to follow. For example, ensuring timings of repositioning was in the skin integrity plan and updates following an incident were completed swiftly. Medicines were managed safely. We found that records and quantities tallied and recording systems were used consistently. Protocols for medicines to be administered as needed were not always in place.

Infection control practices were in place and staff knew what they needed to do. However, we identified occasions when staff were not wearing their masks correctly. The carpets in the lounges needed to be cleaned or replaced.

People had their care needs met. In most cases this was done in a person-centred way. However, we raised awareness of some areas needing a review to ensure care was always delivered in a way that promoted people’s choices and dignity. For example, respecting people’s gender preferences of staff.

People were supported to eat and drink well and had access to health and social care professionals as needed. People had access to food, drink and call bells throughout our inspection. We saw that staff were friendly in their approach with people and knew people well. People and relatives were positive about the staff team’s approach and abilities.

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. People told us they could choose how care was delivered and how to spend their day.

People and staff said there was generally enough staff to meet people’s needs. Agency staff were supporting the home, many having worked at the home often. Staff told us they had enough training and felt well supported.

People had a range of activities and events to get involved with and told us they enjoyed. There was a quarterly newsletter shared with people and relatives to recap on what they had been joining in with. People had end of life care plans in place and staff had been trained. Feedback about the care people received at the end of their lives was positive.

People had their communication needs assessed on moving into the home and reviewed monthly. Information could be given in a different format and assistive technology available when needed. Staff spoke with people in their preferred way.

The manager was new in post after previously working in the home as a deputy manager. There were management systems in place and the manager was further developing these to drive improvements in the home. People, relatives and staff were positive about the management and leadership in the home.

Lessons learned were recorded and actions implemented. We found that they had made improvements in the areas raised at previous inspections.

Following our feedback, action was taken to address all points raised. These actions, and supporting records provided, gave us reassurance that any risks were mitigated.

We found the manager to be open and responsive to feedback. Visiting healthcare professionals told us that the management team and staff worked well with them.

People told us that their needs were met, and staff were nice. They told us they felt safe. Relatives were confident about the standard of care and told us staff were friendly. Relatives felt the management team and staff were approachable and knew people well. People and relatives were confident to raise any concerns and the manager responded to them appropriately. They looked for themes and trends.

Rating at last inspection

At the last inspection the service was not rated (published 12 January 2022.). The last rating for this service was requires improvement (published 22 April 2021).

Why we inspected

We undertook a focused inspection of safe and well led based on our internal monitoring of the service and to follow up on information which we had received about the service about management, infection control and staffing.

We inspected and found there were improvements across the service, so we widened the scope of the inspection to become a comprehensive inspection which included all key questions.

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.

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Westbourne Care Home on our website at www.cqc.org.uk.

Follow up

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