Westhorpe Hall

Updated 24 August 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 Care Act 2014.

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

This inspection was carried out by one inspector.

Service and service type

Westhorpe Hall is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service did not have a manager registered with the Care Quality Commission. Registered managers and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the inspection there was a deputy manager responsible for day to day management and a nominated individual with oversight responsibility.

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. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection

We spoke with three people who lived in the service and three relatives about their experience of the care provided. We also spoke with five members of staff and members of the providers management team.

We observed people's care to help us understand the experience of people who could not talk with us. We reviewed a range of records. This included three people's care records and medication records. We looked at a variety of records relating to the management of the service, staff rotas and quality assurance records.

After the inspection

We continued to seek clarification from the provider’s representatives off site to validate evidence found and held a feedback meeting with the provider and other senior staff.

Updated 24 August 2022

About the service

Westhorpe Hall is a residential care home providing personal care to nine people at the time of our inspection. The service supports older people including people living with dementia. The service can support up to 21 people, but the first floor of the service had been taken out of use by the provider. The service is in a listed building with enclosed gardens and is located in a rural area.

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

The arrangements in place to keep people safe were more robust and risk management systems had been strengthened since our last inspection. Recording of safety checks had improved but there were some omissions in the recording of welfare checks.

The service continues to experience challenges recruiting staff and was dependent on agency staff. This was compounded by issues around staff deployment and a lack of activities. We were assured by the provider that they had a plan in place to address our findings.

Incidents and accidents were logged and reviewed to identify learning. Agency staff received an induction into working at the service.

Medicines practice had been strengthened since our last inspection. Medicines were securely stored and competency assessments for staff were in place.

Safeguarding concerns were managed in a transparent way and although we identified one omission, we were assured that overall practice had improved since our last inspection.

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.

There were systems in place to manage infection control and personal protective equipment (PPE) was appropriately stored and practice audited. The laundry was however disorganised making it difficult to separate clean and soiled linen, the provider told us that they had plans to refurbish this area.

The service has not had a stable leadership team for some time. The providers new management team had started to provide some stability and staff morale was improving. People and their relatives expressed confidence in the changes that had taken place and spoke highly of staff.

Audits on quality and safety had been completed but further work is needed to embed changes at 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 and update

The last rating for this service was inadequate (18 March 2022). The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since (18 March 2022). During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We undertook this inspection to check whether the Warning Notice we previously served in relation to Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met.

This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Westhorpe Hall 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.