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Archived: Westbrook House Inadequate

Inspection Summary

Overall summary & rating


Updated 21 August 2021

About the service

Westbrook House is a residential care home providing personal care to people with a learning disability and/or autistic people. The service can support up to seven people. At the time of the inspection there were five people living in the home. Westbrook House is a terraced house set over four floors.

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

People living in the service had been exposed to risk of harm. Risks relating to numerous areas including the environment had been poorly assessed and responded to. Safeguarding systems were ineffective and exposed people to risk of abuse. Incidents were not always reported and when incidents occurred staff did not take effective actions to mitigate risks. People were exposed to an increased risk of infection, this included in relation to COVID-19. Staffing was poorly managed, and this impacted on the ability of staff, including managers, to carry out their roles. Medicines were not being safely managed.

People were not being supported by staff who had the correct skills and training. Best practice guidance and legislation was not being applied. The environment had been poorly maintained and was dirty. People were living in dirty bedrooms with mould and damp. Staff were not supporting people in the service to eat healthily and in some cases people’s individual needs around their diet were not met. Staff were not proactive in managing or responding to people’s healthcare needs.

People were not supported to have maximum choice and control of their lives and staff did not 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.

The dirty poorly maintained environment was not respectful and did not promote their dignity. People were not supported by staff who paid attention to their needs and ensured these were met. Staff did not always treat people with respect. People’s rights were not fully protected and as a result their property and finances were not always treated respectfully. Staff were not effectively utilising the systems in place to ensure people were fully involved in their care.

The support provided had not adequately met people’s needs or been provided in a timely manner. A lack of person-centred planning meant people’s needs were not considered and met, this was across a wide range of areas including social contact and recreational activities. Staff were not utilising communication systems to ensure people’s communication needs were met.

There was a lack of leadership and management in the service. There had been no registered manager in post since April 2020. Staff spoke about poor communication and support which hampered their ability to meet people’s needs. Governance systems were ineffective and where issues had been identified action to drive improvement had not taken place. The incident reporting and monitoring system was ineffective, and incidents had not been reported where required including to CQC.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. The model of care being followed did not maximise people’s choice, control and independence. The care was not person-centred and did not promote people’s dignity and human rights. There was a lack of person-centred culture and values within the service. These concerns had contributed to people’s individual needs not being met and being placed at risk of harm. The issues iden

Inspection areas



Updated 21 August 2021

The service was not safe.

Details are in our safe findings below.



Updated 21 August 2021

The service was not effective.

Details are in our effective findings below.



Updated 21 August 2021

The service was not caring.

Details are in our caring findings below.



Updated 21 August 2021

The service was not responsive.

Details are in our responsive findings below.



Updated 21 August 2021

The service was not well-led.

Details are in our well-Led findings below.