18 July 2022
During an inspection looking at part of 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.