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Inspection Summary

Overall summary & rating


Updated 18 September 2021

About the service

Westgate House is a care home that is registered to provide accommodation and personal care for up to 44 older people including people living with dementia. At the time of inspection 35 people were using the service.

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

People were not consistently protected from harm. Physical interventions were not recorded appropriately, and unexplained injuries were not always investigated to identify a cause. Not all safeguarding's had been notified to the relevant professionals.

Risk assessments were not always in place or contained enough information. Staff did not always have the information required to support people safely. Some care plans held conflicting information and some care plans had missing information.

People’s care was not reliably recorded. We found gaps in the recording of repositioning charts, oral care, food, fluids, cleaning and incident forms. This meant we were not assured tasks had been completed.

Medicine administration required improvement. People were at risk of not receiving their medicines as prescribed. Staff did not always record they had given people their medicines or explained why they had given ‘as required’ medicines or their effects.

The environment required attention. The home appeared dirty with stains on walls, floors and furniture. We found damaged furniture. Cleaning records had gaps in the recording.

Improvements were needed to promote people’s independence, dignity and respect. We observed limited positive interactions between people and staff. Activities were limited and people stayed in one communal area for the day.

People’s communication needs required further development. We found people who required specific communication aids, did not always have this need met.

Systems and processes to ensure oversight of service required improvement. We found limited governance systems to ensure care was delivered, and records were kept and maintained. Policies and procedures were not always followed.

Lessons learnt and improvement of the service was lacking. Feedback from staff, people and relatives had not been sought to improve and monitor the service. Trends and patterns were not always reviewed and shared.

People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Staff were recruited safety and completed an induction, training and shadow shift before starting work. However, not all staff had received refresher training.

People were supported to access healthcare. Referrals were made to external professionals such as speech and language therapists, dieticians and GP’s.

For more details, please see the full report which is on the CQC website at

Rating at last inspection and update.

The last rating for this service was requires improvement (published 4 May 2020) and there was one breach of regulation. 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 not been made and the provider was still in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about cleanliness, oversight, records and safeguarding. A decision was made for us to inspect and examine those risks.

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.

We have found evidence that the provider needs to make improvement.


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account o

Inspection areas



Updated 18 September 2021

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 18 September 2021

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 18 September 2021

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 18 September 2021

The service was not always responsive.

Details are in our responsive findings below.



Updated 18 September 2021

The service was not well-led.

Details are in our well-led findings below.