All inspections: Whitehaven Residential Home

Date of Assessment: 2 to 16 March 2025. This was a responsive inspection of the following key questions, safe, effective, responsive and well led. It was completed to follow up on the enforcement action taken after our previous inspection. This service is a residential care home for up to 15 people, providing support for older people who may be living with dementia.

The provider was previously in breach of legal regulations in relation to consent, safe care and treatment, safeguarding, safety of the premises and governance. Whilst we found improvements had been made, further work was required, and the provider remained in breach of these regulations.

The provider did not always control potential risks in the care environment, for example, the required works in relation to fire safety were still in the process of being completed.

The provider did not have clear responsibilities, systems of accountability and good governance systems. They did not always ensure records were robust and fully evidenced the care people received.

The provider could not demonstrate they always had a positive culture of safety, due to a lack of records. The provider did not demonstrate how they always managed risk to people well. The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The provider had not obtained written evidence of people’s consent to their care or recorded how they ensured legal requirements were met where people lacked the capacity to consent. Therefore, they could not always evidence the assessments they completed when people had restrictions in place.

The provider was previously in breach of legal regulation in relation to notifications. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.

Through our observations, speaking with relatives, professionals, staff and the provider. We were assured people received the care they required in a person centred manner. We saw a low level of impact of the breaches on the delivery of people’s care and their experience and safety. This was due to the stable staff team who knew people well and understood their care needs and risks.

Although further work was required to achieve compliance with the breaches. We saw the provider was motivated and had made progress. In some areas, such as with the work on fire safety, progress had been inhibited due to factors, outside their control. The provider understood the need to be able to evidence the work both they and staff completed.

It will take further time for them to be able to fully establish and embed all of the systems they need and to delegate responsibilities to staff. To ensure the whole team is clear about the expectations of them within their role and their contribution to achieving the aims and objectives of the service.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Date of Assessment: 21 May to 24 June 2025. This was a responsive inspection of all 5 key questions triggered by our ongoing monitoring of the service. This service is a residential care home for up to 15 people, providing support for older people who may be living with dementia. At the time of the inspection there were 11 people living at the service.

We found improvements were needed in many aspects of the service for people’s safety, welfare and rights. These included governance, record keeping, management of risks relating to people, safety of the environment, medicine management, safe staffing, and consent. Management oversight, governance systems and audits were either not in place or had not been used effectively to assess, monitor and improve the quality and safety of the service. Staff did not have access to people’s care plans for a period of 2 weeks after the service changed over their care planning IT system. Care plans adapted after our site visits, and in response to our feedback, still did not always reflect people’s assessed needs or always contain sufficient information for staff. We found occasions when the provider had not kept all the required records in relation to staff’s recruitment.

We observed there were sufficient staff available to support people. Staff knew people’s needs, preferences and life histories well. This enabled staff to support people in a person-centred and respectful way.

Staff and the provider treated people with kindness, empathy and compassion and respected their privacy and dignity. We found staff responded to people’s needs as they occurred and acted to minimise any discomfort or concern.

At the inspection we identified 6 breaches of regulations in relation to consent, safe care and treatment, safeguarding, safety of the premises, governance and notifications.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.

We have asked the provider for an action plan in response to one of the concerns found at this assessment.

Whitehaven residential care home is registered to provide accommodation and personal care for up to 15 older people, some of whom live with dementia. Accommodation is arranged over two floors with stair lift access to all areas. At the time of our inspection 15 people lived at the home.

We found the following examples of good practice.

Systems were in place to support visitors to access the service safely and reduce the risk of them spreading infection.

Risk assessments for staff at higher risk or with underlying health conditions were carried out to minimise the risk and spread of infection and keep people safe. Everyone in the staff team had received the vaccine to protect them from coronavirus.

The registered manager was communicating with people, staff and family members regularly to make sure everyone understood procedures and precautions being taken, and how to keep people safe. The registered manager worked with the care staff team to ensure infection prevention and control measures were followed.

The service had enough personal protective equipment (PPE) to meet current and future demand. Staff were using PPE correctly and disposal was safe.

There were up to date infection prevention and control (IPC) policies and procedures, backed up by regular newsletters and there were posters around the home. There was a COVID-19 folder accessible to all staff. Staff had received training and COVID-19 testing was taking place in accordance with current guidance.

We carried out an unannounced inspection of this home on 10 August 2017. The home is registered to provide accommodation and personal care for up to 15 older people, some of whom live with dementia. Accommodation is arranged over two floors with stair lift access to all areas. At the time of our inspection 15 people lived at the home.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Risk assessments were in place which informed plans of care for people to ensure their safety and welfare, and staff had a good awareness of these. Incidents and accidents were clearly documented and investigated. Actions and learning were identified from these and shared with all staff.

People were supported by staff who had a good understanding of how to keep them safe, identify signs of abuse and report these appropriately.

Robust processes to check the suitability of staff to work with people were in place. There were sufficient staff deployed to meet the needs of people and they received appropriate training and support to ensure people were cared for in line with their needs and preferences.

Medicines were administered, stored and ordered in a safe and effective way.

People were encouraged and supported to make decisions about their care and welfare. Where people could not consent to their care, staff sought appropriate guidance and followed legislation designed to protect people’s rights and freedom.

People received meals which were well presented and in line with their needs, preferences, likes and dislikes. Staff dined with people and supported them if needed in a calm and supportive way.

Staff were calm, kind and gentle in their interactions with people and people responded well to the support offered to them. People’s privacy and dignity was maintained and staff were caring and considerate as they supported people. Staff involved people and their relatives in the planning of their care.

External health and social care professionals were involved in the care of people and care plans reflected this.

The registered manager promoted an open and honest culture for working which was fair and supportive to all staff. Staff felt supported in their roles and people and their relatives spoke highly of all staff.

Effective systems were in place to monitor and evaluate any concerns or complaints received and to ensure learning outcomes or improvements were identified from these. Staff encouraged people and their relatives to share their concerns and experiences with them.

At our last inspection of Whitehaven in December 2014 we found this service to be good. At this inspection the home remained good.

This inspection took place on 9 December 2014 and was unannounced. When we inspected this service on 6 June 2013 we found it was not meeting minimum standards in the management of medicines. At a follow up inspection on 27 August 2013 the provider had made the necessary improvements. This inspection found the improvements had been sustained.

Whitehaven Residential Home is a care home which does not provide nursing care. It is registered for 15 people, and at the time of our inspection was fully occupied. People living at the home were older people and people living with dementia. They were accommodated on two floors. Shared areas comprised a dining area, a lounge and a quiet lounge. There was an enclosed garden with a paved area. A sign near the front door announced that Whitehaven Residential Home was a “pet-friendly home”.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are “registered persons”. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us it was a pleasant place to live and they were looked after well. One family member commented “unique and lovely home with exceptional care”. People were kept safe. Staff had a good understanding of the risk of abuse, how to recognise it and how to report concerns. Risks to people’s safety were assessed and managed in a way that maintained their liberty. There were enough, suitable staff to support people safely. Arrangements were in place to keep medicines safely.

Staff were supported to provide a good standard of care. They received appropriate training and the manager had an effective system of appraisal and supervision. Staff checked people ate and drank enough to avoid the risk of poor nutrition and hydration.

Where people were able to consent, care and support were provided in accordance with their wishes. However where people were not able to consent, we found inconsistencies in the provider’s records of mental capacity assessments.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards which apply to care homes. We found the manager had procedures in place designed to safeguard people against the risk of being unlawfully deprived of their liberty. However they had not completed the process of making the necessary applications where people were at risk. We have made a recommendation about mental capacity assessments and Deprivation of Liberty Safeguards.

A family member had commented, “Staff take time to listen and care for residents”. We found the positive, caring relationships established by staff were extended to people’s families and pets. Staff encouraged people to be involved in their care and support and made sure they maintained their dignity and privacy.

People had opportunities to take part in appropriate activities if they wished to do so. Staff responded to people’s preferences and changing needs, and adapted their care and support accordingly.

The service was homely and friendly. A visiting social worker had commented in the visitors’ book, “warm and pleasant atmosphere”. Staff had a strong team work ethos and people’s relations considered the home was well managed. There was a system of checks and audits to make sure the quality of service was sustained.

On the day we inspected there were 15 people living at the home. During our inspection we spoke with three staff and two people who use the service.

We carried out an inspection on 6 June 2013 when we identified that people were not always protected against the risks associated with medicines. The provider wrote to us telling us what action they would take.

We carried out an inspection on 27 August 2013 to review the progress the provider had made in taking action to be compliant in the area where we had previously assessed them as non-compliant.

We found that the provider had taken steps to improve administration and recording of medicines.

Staff told us of the medicine adminstration policies, new records and training that had been introduced following our visit.

People we spoke with were happy at the home and we observed that staff intervened and offered support when needed in a sensitive manner.

On the day we inspected there were 15 people living at the home. During our inspection we spoke with three staff and four people who use the service. People we spoke with said that the staff 'Are very caring'. One said 'The girls are lovely'.

People's consent was obtained prior to any care and support being provided. There was clear guidance in the home's policies and procedures about what action should be taken if staff thought a person did not have the capacity to make their own decisions. The home ensured relevant health care professionals were contacted when needed.

We observed interaction at lunchtime for approximately 80 minutes, we saw that members of staff spoke to people with respect and sensitivity.

We carried out an inspection on 28 December 2012 when we identified concerns with record keeping, for example the home had not ensured that accidents and incident records had been properly managed for all people. We made a compliance action asking the provider to take action in order that we were reassured that people were in receipt of safe and adequate care. The provider wrote to us and told us what action they were going to take.

At this inspection we found that the provider had taken steps to improve record keeping. However, we found people were not always protected against the risks associated with medicines.

During our inspection we spoke with three members of staff and the service provider. Due to most residents having complex needs, we were only able to seek the views of two residents. We spoke with a District Nurse who was on a professional visit to the home. The provider also asked two residents family members and a former resident's family member to speak to us.

A resident told us "the staff are very good. I came in because I was sick; my health is really well now." Another resident told us "they take great care of me." We spoke with a District Nurse who was visiting the service. The District Nurse told us that their service visited the home everyday, and said "I've never seen anything I've been concerned about. The residents always appear clean, well dressed, and look well fed."

We found that the home had some room for improvement with regards to record keeping. We also found that the provider was working to cover a housekeeping vacancy on the day of our visit.

During our visit we spoke with three people who live at the home, one relative, two staff and the provider.

People at the home told us that they liked living at the home and that the staff were helpful with nothing being too much trouble and the staff were easy to talk to. There were cats living at the home, and people liked having the cats as extra company. Relatives we spoke with told us that the home was 'homely' and spoke about the provider with high regard and said they could also speak freely with staff. The staff conducted themselves in a caring and professional manner.

We observed lunch being served and how staff interacted with people and ensured choice about daily issues such as where to sit. One person told us about the activties and games available, the activities on the day of our visit was a quiz and flower arranging.

Staff told us they received regular training, were supported by the management of the home and that they could speak with senior staff about any concerns they had about the running of the home.

These older reports are from our old approaches to inspection, including those from before CQC was created.

Whitehaven Residential Home

All Inspections

During an assessment under our new approach

During an assessment under our new approach

3 February 2021

During an inspection looking at part of the service

10 August 2017

During a routine inspection

9 December 2014

During a routine inspection

27 August 2013

During an inspection looking at part of the service

6 June 2013

During an inspection looking at part of the service

28 December 2012

During a routine inspection

24 January 2012

During a routine inspection

Reports under our old system of regulation