Westacre Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to staffing and good governance.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff understood what safety incidents to report, to whom and how. They felt confident about reporting incidents and told us any required actions following incidents, were taken. Health care professionals confirmed they were informed of relevant safety events at the service.

The registered manager reviewed incident forms, which enabled them to check any required actions had been completed and if staff had followed relevant guidance, such as the local authority falls protocol, used if people fell.

The registered manager completed a monthly analysis of a range of different types of incidents to identify trends and any improvements required. Learning from incidents and trends analysis was then shared with staff both through messages sent via the electronic care planning system and face to face staff meetings.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People's pre-admission assessments were completed before their care commenced. The provider had processes in relation to people's admission and discharge, which ensured key information was documented and shared with relevant professionals and external services. People told us their transition to the home had been straight forward. A person’s representative said the move was, “all very smooth.” Staff made the required referrals to health care professionals in a timely manner, after people moved in, which ensured continuity of care.

The provider did not always consider the impact of practices and processes upon people’s rights and freedom.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

The staff handover sheet provided key information about people and where relevant whether a DoLS had been applied for or authorised. Following the site visit we asked for the DoLS application for a person the handover sheet stated DoLS had been applied for, we were advised a DoLS application had not been made. Staff were provided with incorrect information, which potentially impacted the person’s freedom and rights. We have been advised this has now been corrected.

There were keypads fitted to the ground floor main corridor doors, which separated the 2 sides of the ground floor main corridor. The keypads prevented people, including those living with dementia who walked with purpose, from accessing the whole of the ground corridor independently. People's liberty to roam was inadvertently restricted. We brought this to the attention of the registered manager who acted to open these doors during the day.

However, people said they felt safe with staff, and they had access to safeguarding information. Staff had undertaken safeguarding training and had access to local and national safeguarding guidance, they understood what to report, to whom and how. The provider cooperated with safeguarding investigations and there was oversight of safeguarding for people's safety both at home and provider level.

People’s records sometimes contained conflicting information about the management of risks to them.

A person's care plan and risk assessments contained conflicting information about the risks to them related to both their diabetes and falls risks. This meant staff might not have either the correct guidance, or insufficient guidance to keep the person safe from any associated risks. We brought this to the registered managers attention; they took the required action.

The staff handover sheet contained conflicting information about which people required re-positioning to mitigate the risk of them experiencing skin breakdown. This created a potential risk if staff relied on the handover sheet for guidance. However, we were assured having reviewed people's daily records relating to re-positioning and the provider’s repositioning audit, that people were re-positioned in accordance with the guidance within their general care plan.

People’s risks relating to moving and handling, weight, skin integrity, moving and handling, choking, continence, bed rails and hydration were assessed and mitigated by staff. As well as individual risks to them for example, related to their behaviours. People told us they had any required equipment to manage identified risks to them, and we saw people had mobility aids, hoists and air mattresses. People were seen to be supported to be transferred safely. Staff spoken with understood people's specific risks and how these were managed. Staff had completed training in areas relevant to the management of identified risks to people.

The provider did not always detect and control potential risks in the care environment. They did not always make sure all equipment checks were completed, it was not always clear from records required safety actions had been completed.

The provider ensured required safety checks on equipment used to transfer people were completed. However, chairlifts, had not recently been inspected in accordance with legal requirements to ensure they were safe to use. We brought this to the attention of the registered manager who acted to ensure the relevant safety checks were completed.

Whilst a Legionella risk assessment was in place to identify and mitigate the potential risks associated with Legionella, a bacterium that can cause Legionnaires’ disease. The provider’s records had not been updated to demonstrate all required actions had been completed. The registered manager provided confirmation afterwards that some recommendations had been addressed, whilst others were being addressed as part of current building works.

A fire risk assessment had been completed. The provider’s records had not been updated to demonstrate all actions required to mitigate identified risks were completed. The registered manager confirmed afterwards that most actions had been completed. However, records reviewed did not provide assurance fire door repairs were carried out promptly in case of fire, although the registered manager advised required actions were taken. The registered manager had recorded the recommendations from the last fire risk assessment to ensure the effectiveness of learning from fire drills were complete. We identified similar gaps when reviewing recent fire drill records. The registered manager since advised a new fire training provider is in place and the fire drill record has been updated to demonstrate previous issues have been addressed.

A health and safety audit had been completed. The provider’s records had not been updated to demonstrate all required actions to mitigate identified risks had been completed. The registered manager provided confirmation afterwards most actions had been completed.

However, overall, the premises were secure. Window restrictors were fitted and subject to monthly checks and chemicals were stored securely. The provider had a process for reporting maintenance issues which were addressed promptly. The provider ensured legally required safety checks were completed in relation to electrical and gas safety.

The provider did not always make sure there were enough staff deployed at all times of the day to meet people’s needs in a timely manner.

The provider had processes in place to determine people’s staffing needs and to monitor staff deployment. However, we received mixed feedback regarding staffing. Some people and relatives told us there were not enough staff and they had to wait for: personal care, for call bells to be answered and for lunch. Feedback included, “There’s not enough staff,” “Sometimes, I wait a long while when I call the bell” and “There’s not always enough staff, especially at lunchtimes.”

Some people felt staff were under a lot of pressure in their work. Their feedback included, “They [staff] are so overworked” and “They [staff] are worked to the ‘nth’ degree.” Staff said they were very busy and it could be challenging. The providers September 2025 staff Stress at Work survey whilst positive overall, showed 63.2 percent of staff agreed or strongly agreed they had to work very intensively, and 52.6 percent of staff agreed or strongly agreed they had to work very fast. The provider had since identified and completed actions, which focused on ensuring staff were clear about their roles and responsibilities, were listened to and communicated with. The May 2026 staff survey showed improvements were being made.

The handover sheet showed at lunchtime there was a high staffing need as a significant number of people required or may require support with their meal. We observed on the first day of inspection, people waited 27 minutes to be served. A person living with dementia repeatedly wandered off whilst they waited. People also told us their food was cold when it arrived. Whilst the registered manager told us this was partially due to the late arrival of kitchen staff, we did not note a significant difference on the second day onsite. Not enough staff were deployed at lunchtime to assist people in a timely manner. The registered manager has since told us they will monitor the timing of when people are supported to the dining table to ensure waiting times are kept to a minimum.

The staff allocation sheet showed there were times in the day when between 3 and 5 of the 8 care staff rostered were off the floor, on rest breaks. Therefore, the number of staff deployed to support people was depleted. At times we could not see many staff. We observed staff struggled to meet peoples' needs promptly; for example, when assisting those who required personal care.

The registered managers weekly call bell audits for May 2026, showed they were aware call bells were not always responded to within the provider’s 5-minute recommended standard and aware of the associated risks to peoples' safety, comfort and welfare. The audits showed despite staff efforts, staff were still not managing to meet the recommended time, although the number of excess call bell response times had reduced.

The number of staff at night was not sufficient to always have staff deployed on the top floor and to be able to provide peoples' care. The registered manager advised this risk was mitigated by staff checking upon people hourly and people at risk of falls had sensor mats to alert staff. They advised staffing of the top floor was to be reviewed later this year, as staffing requirements would increase once the planned building works were completed and capacity increased.

However, required staff pre-employment checks were completed, and staff received an induction to their role, ongoing supervision and an annual appraisal. Staff training compliance was high, and staff were provided with a range of both required and role specific training.

The provider did not always assess or manage all potential risks of infection.

We found in the 2 kitchenettes located on the ground and first floors a number of items in the cupboards had been opened but lacked a date of opening. Therefore, there was a potential risk people may have been provided with food which was not within date for use. In the main kitchen, there was a schedule to show which cleaning tasks should take place and staff advised cleaning was completed. However, there were no records to evidence cleaning had been completed as required, to mitigate the risk of infection. People’s bed bumpers and crash mattresses were not included on the monthly mattress and bed check, and we found a bed bumper and a crash mattress with their outer layer compromised which presented a risk.

The providers last infection prevention and control (IPC) audit stated single-use items were disposed of after use. A person’s care plan stated they had capacity to request staff remove single use items after use. However, we saw they chose not to; their care plan did not include guidance for staff to regularly check if these items had been used and therefore required disposal. This was important as the person was vulnerable to infections.

Overall, the premises were clean, and staff followed and completed the cleaning schedules provided for the communal areas and people’s bedrooms. The kitchen had a food hygiene rating of 5 which is very good. Staff had received relevant training and were noted to use personal protective equipment (PPE) in line with guidance. We saw PPE was available throughout the home. There was an infection control lead for the service.

The provider did not ensure all aspects of medicines management were robust.

On the first day we found 3 topical creams and 2 people’s insulin pens lacked a date of opening. There was a potential risk staff may have administered them not knowing if they were still safe or effective. The registered manager acted and addressed this with staff immediately and updated their topical creams audit to include the date creams were opened. However, on the second day we then found 2 tubs of thickener used to thicken peoples’ drinks lacked opening dates and a further 1 lacked a label to determine who it was prescribed for. We brought this to the registered manager’s attention, who took the required actions.

However, staff administering medicines completed the providers online medicines training. Processes were in place to order and return medicines safely. People’s medicine administration records were complete. People received time critical medicines correctly and there was guidance for high-risk medicines. People had risk assessments for flammable topical creams and had posters regarding the associated risks in their bathrooms. People had protocols for medicines they took ‘as required’ and staff used pain scales to identify if people were in pain. Where people were on covert medicines the correct processes had been followed. Controlled drugs were stored and managed safely. Processes were in place to audit medicines and to identify, report and review any medicines errors.