West Hill Care Home

Date of inspection: This assessment took place between 14 October 2025 and 13 November 2025. We visited the service on 14 October 2025. During this assessment, we looked at the key questions of Safe, Caring and Well-Led. We found 4 breaches of the regulations in relation to safe care and treatment, dignity and respect, safeguarding people from abuse and good governance.

This inspection was carried out to review these breaches of regulation, and to address safeguarding concerns we had received around people’s care and treatment. The service was previously rated required improvement but has now changed to inadequate.

West Hill Care Home provides care and support for older people, some of whom are living with dementia, in one building over 4 floors. The service can support up to 77 people.

There was a closed culture at the service. A "closed culture" is a poor culture that can lead to harm, including human rights breaches and abuse. We found a poor culture across the entire service, which had not been recognised or addressed by the provider.

We found a continued breach of regulation in relation to safe care and treatment of people, including the management of medicines. People were not always protected from avoidable harm because risk assessments were not always clear, comprehensive and up to date. They did not always contain enough information about people’s risks and mitigation strategies for staff to provide safe and effective care.

The systems in place in place to manage incidents and accidents was not effective. Some incidents were not reported by staff in a timely manner and there had been some delays. Where people where distressed records were poor which impacted on how patterns and trends could be understood. Staff continued not to always identify safeguarding concerns when they arose.

People’s support was not always provided in a safe way as guidance from health care professionals was not always followed. Staff did not always follow safe care practices. There were areas where there was a lack of guidance for staff such as supporting people who used a hoist to move. There were gaps in the care provided for people.

Risks from the environment were not always well managed. Items which could be unsafe if they were accessed by people were not always secured away. People’s evacuation plans lacked details. The provider had not taken sufficient action to ensure staff could evacuate people in a reasonable amount of time in the event of an emergency. Appropriate checks were completed on utilities such as gas and electric.

Staff had not always completed the training they needed, and some training had been delayed. We identified areas where staff skills needed to be improved such as when supporting people to eat or providing dignified care.

The provider told us they used a dependency tool to calculate staffing levels. However, feedback from staff regarding staffing levels was mixed.

People’s medicines were not always safely managed to ensure medicines were always administered as prescribed. Some people had ‘as and when’ medicines for when they were upset. It was not always clear why these medicines were administered to people when they were.

The service had not improved since the last inspection and concerns had increased. There was no clear effective strategy for improvement. There were governance systems in place, however, they had not proved to be effective at driving forward positive change. The culture of the service needed to be improved to ensure there was a focus on learning and safety. Governance systems needed to be improved.

We were not assured leaders at the service had the skills and knowledge they needed to credibly lead the service. Leadership had not led to improvement within the service and there was a lack of leadership from the provider, who was also the nominated individual.

Feedback from staff regarding if they were heard when they spoke up was mixed. However, staff did feel the registered manager valued diversity.

The service was clean.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we user our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

We carried out this assessment on 10 February 2025. During this assessment we looked at the key questions of Safe, Effective and Well-led. The assessment was triggered by some safeguarding concerns we had received around people’s care and treatment. West Hill Care Home is a service which provides personal care and accommodation for up to 77 people. Some people have health conditions which require them to receive care and other people were living with dementia. At this assessment we found staff were not always aware of their responsibility to keep people safe and report concerns to the relevant authorities. We found a number of incidents which should have been reported as potential safeguarding concerns and we also found there was insufficient information around risks for some people. We found staff were not always following the principles of the Mental Capacity Act 2005, specifically in relation to the use of CCTV in the service. However, this was addressed immediately after our inspection. The new manager had started to make improvements to the service, particularly in relation to the number of unexplained accidents and incidents. But further work was needed to strengthen the governance processes at the service to help ensure people consistently received high quality care, documentation was accurate and shortfalls were identified and actioned. Staff followed good medicines practices and also worked with external health care professionals to help support people to remain healthy. Staff knew people and had time to sit and chat with them as there were sufficient staff on duty. Staff enjoyed working at the service. They felt supported and said they received sufficient training and were comfortable speaking up. We found the registered provider was in breach of four regulations relating to safeguarding people from abuse, safe care and treatment, need for consent and good governance.