Westmorland Court Nursing and Residential Home

Westmorland Court Nursing and Residential Home is a residential care home providing personal and nursing care for up to 48 people aged 65 and over. At the time of this inspection the service was supporting 32 people. The service provides care for older people, older people living with dementia. The accommodation is provided over 3 floors.

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

Medicines were not always being managed safely. However, since the last inspection in 2019 where we found some similar concerns, we did find that some improvements had been made to address those concerns at that time.

Most risks relating to people's needs had been identified. However, some assessments for managing the risks were not in place. The registered manager took immediate action to ensure these were completed. There were enough staff to adequately support the number of people using the service. Recruitment processes in place ensured staff were suitable to work with vulnerable people.

Systems were in place to record accidents and incidents. These were consistently monitored to identify any lessons learned, themes or trends. Safeguarding incidents were identified and shared with the local authority. However, not all of the incidents had been notified, as legally required, to us. We have made a recommendation about submitting statutory notifications.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Training records seen demonstrated appropriate and relevant training was completed. Referrals were made to other healthcare services where necessary. People told us they thought the care they received was very good and spoke positively about the staff who supported them. People told us the staff treated them with respect and dignity and were kind and caring towards them.

There was regular oversight of the safety and quality of the service. However, the processes in place did not identify all the concerns we found with the safe management of medicines. We have made a recommendation the provider further develops the systems and processes used to oversee the quality and safety of the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update.

The last rating for this service was requires improvement (published 28 August 2019)

We carried out an unannounced comprehensive inspection of this service on 17 June 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe management of medicines.

At the inspection on 17 June 2019 we also made a recommendation about checking practical training for the management of medicines. We also made a recommendation at the last targeted inspection published 16 November 2022 about having a robust system in place for recruitment checks for agency staff. At this inspection we found the provider had acted on these recommendations and had made those improvements.

Why we inspected

This inspection was prompted by a review of the information we held about this service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

At this inspection we found the provider was in breach of regulation. We found no evidence during this inspection that people were at risk of harm from this concern.

The overall rating for the service has remained as requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this report.

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.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Westmorland Court Nursing and Residential Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified a breach in relation to the management of medicines at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Westmorland Court Nursing and Residential Home is a care home providing personal and/or nursing care for up to 48 older people, including people living with dementia. At the time of the inspection there were 38 people living in the home.

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

We noted a concern where a person may not have received emergency care as quickly as they should. This was highlighted to the registered manager and provider representative. They took action with the staff involved and instigated an internal review of what may have gone wrong. In the 2 other cases we reviewed, we were assured the service had appropriately elevated concerns to the relevant healthcare professionals.

We established some concerns around the use of staff employed through a staffing agency. The service could not be completely assured they were appropriate to work with vulnerable people. Required documentation was unavailable and the registered manager resolved the matter during the inspection process. They said a revised system of check would be implemented to ensure thorough checks were in place in future.

Rating at last inspection

The last rating for this service was requires improvement (published 29 August 2019).

Why we inspected

The inspection was prompted, in part, by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the full circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk when people become seriously unwell. We had also received concerns about the service's use of agency staff. This inspection examined those risks.

We use targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question. We found no evidence during this inspection that people were at risk of further harm from these concerns.

You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Westmorland Court Nursing and Residential Home on our website at www.cqc.org.uk.

Follow up

We shared our findings with partner agencies. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Westmorland Court Nursing and Residential Home is a care home providing personal and/or nursing care for up to 48 people with a range of physical and mental health needs. At the time of the inspection there were 39 people living in the home.

The care home accommodates people across three floors, each of which has separate adapted facilities.

We found the following examples of good practice.

The provider had established systems to prevent visitors from spreading and catching infections. They had followed guidance on supporting safe visiting including a comprehensive questionnaire to ensure they were safe to visit. Visitors were also screened for symptoms and their contact details were recorded to support the NHS Test and Trace service.

Social media platforms were used to facilitate contact between people and their relatives where physical visiting was not possible. Where appropriate, people were supported by staff to use this technology and this included the use of handheld devices.

The provider had established some safe admission procedures for staff to follow. This included requiring new people to have a negative COVID-19 test before moving into the home, a further test during residency and to self-isolate in their bedrooms. However, processes needed to be improved when people were admitted who were not vaccinated.

During our visit we observed staff using Personal Protective Equipment, (PPE) safely. The provider had ensured sufficient stocks of appropriate PPE were available to protect people. However, the locations of some PPE stations and disposal bins needed to be improved to reduced the risk of transmission of infection.

People living in the home and the staff were tested regularly for COVID-19. The provider had also supported staff and people to receive COVID-19 vaccines and boosters.

The home was clean and hygienic. Comprehensive cleaning schedules were in place.

The provider had infection prevention and control policies and procedures. These needed to be improved to reflect processes the service was using and to reflect best practice.

The provider could adapt the layout of the building to support safe cohorting in the event of an outbreak.

Westmorland Court Nursing and Residential Home is a residential care home registered to provide accommodation, nursing and personal care for up to 48 people, some of whom may be living with dementia. Accommodation is provided over three floors. At the time of the inspection 38 people were living in the home.

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

The registered manager had completed audits in the home to support quality checks but had not identified where improvements needed to be made to the management of people's 'as required' (PRN) medicines, their self-administration and the storage conditions of some medicines.

Staff received appropriate training and supervision to carry out their roles and help keep people safe. We noted that a member of care staff who had been assessed as capable to administer medicines did not follow best practice guidance with as required medicines. We have made a recommendation about checking staff’s practical understanding and application of their training with regard to the safe handling of medicines.

People told us staff always respected their dignity and privacy and that they had control over the support they received. We saw that staff were kind and caring towards them. We were told, “It is all nice and clean and homely.” Relatives were generally positive about the support their family members received from staff. We were told, “They have 24- hour nursing, which is very reassuring.”

Staff safeguarded people from abuse and assessed risks to people so action could be taken to mitigate them. The registered manager acted to help make sure any lessons learned when things went wrong were put into practice.

The service had environmental and fire safety checks and a maintenance programme to ensure equipment was safe for use.

There were effective recruitment systems being followed within the home to help make sure staff were suitable to work there. The registered manager used dependency tools to help make sure there were enough suitable staff working to support people safely. People told us staff attended quickly when they called them.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People received support with food and nutrition and people told us they enjoyed the meals. Staff helped them gain access to a range of healthcare professionals, including the dietician, as they needed them.

The provider employed an activity coordinator. They encouraged and supported people to be involved in a range of organised activities and to be able to spend time on their own interests.

Clear complaints procedures were in place to address any issues at the service.

The provider had systems in place to monitor the quality and safety of the service, although some had not been as effective as others in highlighting faults. People, relatives and staff were positive about the way the service was run. Staff stated they felt supported and appreciated by the registered manager.

We identified one breach of the Health and Social Care Act (Regulated Activities) Regulations 2014 around the safe management of as required medicines, self-administration and storage. You can see what action we have asked the provider to take at the end of this full report.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 1 August 2018). At this inspection the service has been rated requires improvement as it met the characteristics for this rating in two of the five key questions. Improvements had been made to three of the five key questions.The service has been rated requires improvement on two consecutive occasions.

Following the inspection the registered manager provided us with a detailed action plan telling us what action they had taken and what action they planned to take to make the required improvements.They provided timescales for completion.

Why we inspected

This was a planned inspection based on the previous rating. We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.

The registered manager did act quickly to provide a plan of how they would improve these areas and by when.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Westmorland Court Nursing and Residential Home on our website at www.cqc.org.uk.

Follow up

We will request an updated action plan from the provider to monitor what they have done to improve the standards of quality and safety. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Westmorland Court Nursing and Residential Home (Westmorland Court) is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Westmorland Court provides accommodation for up to 48 adults, who require help with personal and nursing care needs. The home is in a semi-rural setting, a short distance from the village of Arnside. A small car park is available at the front of the building. The home is arranged over three floors with communal bathing and toilet facilities being appropriately located throughout the building. There are stairwells in the home for access to the upper floors, although a passenger lift is also installed for people who live there and visitors to use. At the time of the inspection there were 34 people living in the home.

A new registered manager was in post following the completion of their registration with CQC in April 2018. 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. A clinical lead nurse was also in post to support the registered manager and oversee clinical matters. Staff we spoke with felt supported by the management team.

At our last comprehensive inspection,18 January 2018, the service was rated overall as Requires Improvement. We found that there were five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to; need for consent; safe care and treatment; safeguarding service users from abuse and improper treatment; fit and proper persons employed and good governance. The management of risks within the environment was insufficient and therefore people were at risk of harm. The kitchen was found to be unhygienic and in need of a deep clean. The management of medicines could have been better, so that people who lived at the home could be better protected against poor medicine practices. These findings constituted a breach of regulations 11, 13 12, 17 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued three warning notices and made two requirements.

Following that inspection, we asked the registered provider to take action to make improvements and complete an action plan to show what they would do and by when they would do this. During this inspection we found that improvements had been made and the registered provider had taken action to improve the quality and safety of the service and the breaches of regulation had been met.

At this inspection on 29 June 2018 people living in the home and their relatives told us they believed the home was a safe place to live. We were told that staff were “cheerful” and “friendly”. We saw occasions when staff displayed empathy and compassion as they comforted people when they became distressed or as helped them around the home. Relatives told us staff responded to people’s needs but that some staff found communication with people living there difficult at times. This was being addressed through an ongoing programme of training and support for overseas staff.

We found that improvements to the processes used when employing people had been made and the recruitment of staff was robust. The checks on the suitability of staff required by regulation had been completed for staff in the home.

The quality assurance and monitoring systems being used to assess the quality of the service provided had been developed to be more effective and quality monitoring visits by the provider and area manager were taking place and were recorded. Audits were undertaken to assess compliance with internal procedures and against the regulations and these were highlighting areas that needed to improve or be acted upon.

At this inspection we saw how people were supported to have choice and control of their lives and staff supported them in the least restrictive way. The policies and systems in the service supported this and that only those who had legal authority to do so could make decisions on a person’s behalf. The service carried out assessments of mental capacity in relation to specific decisions. Where necessary applications for Deprivation of Liberty authorisations had been made to restrict a person’s liberty in their best interests.

People’s care plans had nutritional risk assessments in place and instructions for specific dietary needs. We have made a recommendation that the service find out more about how to make menu choices clearer so everyone knows exactly what the alternatives are for all meals and snacks.

We looked at the risk assessments in place at this inspection. We found all the recommendations made by the fire officer had been carried out to make the premises safe. The fire risk assessment and fire safety policy had been updated by an independent company in February 2018. We saw that Personal Emergency Evacuation Plans [PEEPs] had been put in place for all those living in the home and emergency equipment was in place for use in such an emergency.

Moving and handling equipment, hoist slings, window restrictors and emergency equipment had been checked to ensure they were fit for purpose. Equipment and appliances in the home had been checked by the maintenance person for faults. Records showed that environmental risk assessments were in place to protect people in the home. Appropriate individual risk assessments had been completed, which helped to make sure people's needs could be safely met. Accidents and incidents were being recorded and analysed for themes.

We found that the kitchen has been refurbished and COSHH (Control of Substances Hazardous to Health) risk assessments have been brought up to date and the relevant staff were receiving HACCUP (Hazard Analysis and Critical Control Point) training. HACCUP is a food safety management system. An inspection by Environmental Health Officer following improvement rated the service at level 5 which is the highest rating that can be achieved.

Records showed that people's needs had been assessed and appropriate individual risk assessments had been completed, which helped to make sure people's needs could be safely met. We have made a recommendation that the service review their procedures for managing records to ensure they are consistently kept up to date.

We observed medicines being administered safely and there was specific information about people’s preferences when taking tablets.

There were sufficient numbers of care and nursing staff to meet people’s needs. We had noted on the rotas that there had been occasions when self-employed staff had worked long stretches of shifts without a break or only a short break. This had been addressed by the registered manager with the staff concerned.

Staff training was ongoing and people had received sufficient training to support people living in the home. Staff were also being supported through regular staff meetings, supervision and appraisals. There was a programme of induction training for new staff and refresher training was booked for all staff throughout the year. The service had a safeguarding policy and procedure as well as guidance on how to report concerns on display in the home for all to see and use. Staff had undertaken safeguarding training and were aware of how to report any concerns they had. We have made a recommendation that the registered manager finds out more about best practice in relation to evaluating staff understanding and application of their training. This would help to make sure that improvements made were being embedded into the systems of working and into the culture of the home.

We saw that the service was working in partnership with other agencies and had made referrals appropriately. Information was recorded about joint work and referrals to other professionals.

Westmorland Court provides accommodation for up to 48 adults, who require help with personal and nursing care needs. The home is located in a semi- rural setting, a short distance from the picturesque village of Arnside. A small car park is available at the front of the building. The home is arranged over three floors with communal bathing and toilet facilities being appropriately located throughout the building. A number of stairwells are available for access to the upper floors, although a passenger lift is also installed.

Shortly before our inspection the registered manager had left employment. The deputy manager was acting as manager at the time of our visit. She was in the process of applying to the Care Quality Commission to be the registered manager of Westmorland Court. 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.

This comprehensive inspection was conducted on 18 January 2018 and it was unannounced.

Our last comprehensive inspection of this service was conducted over two days on 4 July 2016 and 6 July 2016 when we found the provider was failing to provide safe care and treatment by the proper and safe management of medicines. This was a continued breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Therefore, we issued a warning notice for the unsafe management of medicines. We subsequently conducted two focussed inspections on 7 November 2016 and 11 January 2017 in order to monitor if improvements had been made around the management of medicines. The warning notice in relation to medicines was found to have been met at the inspection conducted on 11 January 2017.

During the inspection on 4 July 2016 and 6 July 2016 we also found the quality monitoring systems were not fully effective in identifying risks. This was a continued breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Therefore, we issued a warning notice for ineffective governance. We subsequently conducted two focussed inspections on 7 November 2016 and 11 January 2017 in order to monitor if improvements had been made around the monitoring of risk. The warning notice in relation to governance was found to be met at the inspection conducted on 11 January 2017.

During the inspection on 4 July 2016 and 6 July 2016 we also found a breach of the regulations in relation to person centred care. At that time people who lived at Westmorland Court were not consistently receiving care or treatment, which had been planned and personalised specifically for their individual needs. Therefore, a requirement notice was issued for regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At this inspection we looked at how the service provided person centred care. Records showed that people’s needs had been properly assessed and the plans of care we saw were well written, person centred documents. The service demonstrated appropriate systems to assess health care risks for people who lived at Westmorland Court and robust systems were in place for the formulation of individuals care plans. Therefore, the previous breach of regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was met on this occasion. However, person centred care and infection control practices could have been further promoted by people being supplied with individual hoist slings, where needed. Also the plans of care did not always accurately reflect the current situation and occasionally they were not being followed in day to day practice. We made recommendations around these areas.

We found those who lived at the home were not protected by the recruitment practices in place, as these were not robust and insufficient checks had been carried out for prospective employees, to ensure they were fit to work with vulnerable people. This was a breach of regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found concerns around the safety of some areas of the home. The management of risks within the environment was insufficient and therefore people were potentially at risk of harm. The kitchen was found to be unhygienic and in need of a deep clean. The management of medicines could have been better, so that people who lived at the home were protected against poor medicine practices. These findings constituted a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service did not always demonstrate appropriate use of the Mental Capacity Act and how individuals were supported in making decisions about their care. This was a breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found staff from the home and community professionals, who did not have legal authority to do so, had in one case signed consent to allow covert medication to be administered to one person who lived at Westmorland Court. Therefore, the provider had failed to act in accordance with the Mental Capacity Act 2005. This was a breach of regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found that a system had been implemented for assessing and monitoring the quality of service provided. However, this was ineffective, as concerns identified during our inspection had not been recognised by the internal auditing system. The minutes of one staff meeting chaired by the provider demonstrated a lack of confidentiality and the recruitment process for the appointment of the new manager was insufficient. This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The environment in which people lived was clean and tidy throughout, although there was an unpleasant odour in one part of the home. We made a recommendation about this.

We had been notified of any significant events, such as deaths, safeguarding referrals and serious incidents, in accordance with the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. However, there was no evidence available to show that lessons had been learned when things went wrong. We made a recommendation about this.

The staff team had received training in safeguarding adults and whistle-blowing procedures. Staff members we spoke with were confident in making safeguarding referrals, should the need arise. The manager told us that she was in the process of implementing annual appraisals for staff. Staff personnel records did not demonstrate that regular individualised supervision had been continued and knowledge checks were not being conducted. We made a recommendation about this.

Complaints were being well managed and people who lived at Westmorland Court were being protected from discrimination. They told us staff were responsive to their needs, although some felt communication was difficult with some staff members. Staff members were seen to be kind and caring. However, on occasions we noted they did not communicate with those they were supporting. We made a recommendation about this.

Records showed that a wide range of community professionals were involved in the care and treatment of those who lived at Westmorland Court. Records showed that surveys had been conducted for those who lived at the home, but staff members and stakeholders in the community had not been asked for their views about how the home was performing. We made a recommendation about this.

A company representative visited the home regularly. However, there was no evidence to show that during these visits discussions were held with people who lived at the home, in order to obtain their feedback or a tour of the premises was conducted in order to make a full assessment of the premises. We made a recommendation about this.

There were sufficient staff on duty on the day of our inspection and we saw staff were always present in the communal areas of the home. We found that disciplinary procedures were followed in response to incidents of misconduct or bad practice.

At this inspection we found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to; need for consent; safe care and treatment; safeguarding service users from abuse and improper treatment; fit and proper persons employed and good governance.

The overall rating for this service is ‘Requires improvement’. The key question of 'Safe' is rated as 'Inadequate'.

If not enough improvement is made when we next inspect the service, so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement, so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service.

The warning notices were in relation to a continuation of breaches of two regulations. These were Regulation 17 (Good Governance), as the quality monitoring systems were still not being effective in identifying all relevant risks to people. The second warning notice was issued for Regulation 12 (Safe care and treatment) because the registered provider had not protected people against the risks associated with the safe management of medication

Following the July 2016 inspection, we completed another unannounced focused inspection on 7 November 2016 to monitor progress with meeting the warning notices. At that inspection, we found that some action had been taken to achieve the improvements stated in the action plan regarding medicines management and governance. Following the focused inspection in November the service rating overall remained Requires Improvement

We, the Care Quality Commission, (CQC) needed to be confident that the registered provider could demonstrate a consistent level of improved practice over time. The registered provider had voluntarily suspended admissions to the home for an agreed period, while the work needed to meet the warning notices was completed. They had kept us informed of their progress during that time.

At this focused inspection on 11 January 2017, we found that the new manager and registered provider had met the breaches of the regulations and the issues outstanding from our previous inspection. At this inspection, we found that all medicines were being administered by qualified nurses. The manager had completed regular audits and competency assessments to assess safe medicines handling in accordance with the home’s medicines policies. Disciplinary action had also been taken with staff where necessary to address poor practices.

This report only covers our findings in relation to breaches identified within the warning notices. We will review our regulatory response and our ratings for safe and well led at the next comprehensive inspection. The service rating overall remains Requires Improvement.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk’

Westmorland Court Nursing and Residential Care Home (Westmorland Court) is registered to provide personal and nursing care for up to 48 people. The home is in a residential area and within walking distance of the centre of the coastal village of Arnside. There is parking available for visitors and a garden area for people living there to use. At the time of the inspection there were 24 people living in the home, 15 of whom were receiving nursing care.

The service did not have a registered manager in post at this inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and associated Regulations about how the service is run.

At the time of the inspection in July 2016, there was not a registered manager in post. A new manager had been recruited by the registered provider. They had been in post since October 2016. The new manager had not yet registered with CQC as required under regulation. They were aware they must do so.

At our inspection in November 2016, we found some issues remained to be addressed to protect people from the risk of harm due to poor medicines management. This was because nurses did not always make clear records of medicines handling and administration and some people had missed doses of medicines because there was none in stock to administer.

At this inspection January 2017, we saw that the new manager had been carrying out detailed medication checks themselves and identifying any shortfalls in a timely manner so they could be addressed. There were policies and procedures in place for staff to follow and these had been reviewed and updated. The medicines administration charts (MAR) were up-to-date and clearly presented to show the medication people had received.

The new manager was monitoring all staff practices and had found that some medication procedures had not been properly followed by nursing staff. The manager had held a nurse’s meeting to take staff through the correct procedures so they were all clear about their professional responsibilities. Disciplinary action had been taken where appropriate with nursing staff who had failed to follow the correct procedures and best practice.

The manager had also carried out observations of practice with staff including moving and handling practices, medicines competence and hand hygiene. As a result, the manager had identified where staff had additional training needs and these needs had been addressed. A training plan for the first three months of the 2017 was in place to help make sure staff received the training they required.

A system of checks and audits was being used for quality assurance and monitoring. This helped the manager to identify and act upon any shortfalls in quality and safety promptly. Since taking up the post, the manager had conducted ‘base line’ checks to form the basis of a full programme of audits. The new manager was clear that a baseline was essential to be able to measure service development and improvement. The monitoring systems and quality management structures the new manager had implemented at our last inspection were now showing where and how the service had improved. This process would need to continue to be used and evaluated to evidence consistency in the longer term.

We could see from audits and action plans the new manager had completed that they had been continuously reviewing the work undertaken to date to comply with the regulations. The checks also allowed the manager to assess what still needed to be completed and embedded with staff. The new manager demonstrated a clear understanding of the areas that had to be completed straight away. We could see that improvement work was being well planned, carried out and evaluated. Any identified changes or improvements were being addressed.

The warning notices were in relation to a continuation of breaches of two regulations where requirement notices had been issued at an inspection in September 2015. This was in respect of Regulation 17 (Good Governance) as the quality monitoring systems were still not being fully effective in identifying risks. It was also in respect of Regulation 12 (Safe care and treatment) because the registered provider had not protected people against the risks associated with the safe management of medication.

We also found at the inspection in September 2015 incidents that had occurred within the home that might affect people’s safety had not been appropriately referred to the local authority safeguarding team or notified to CQC. We found that the registered provider had also not always acted in accordance with the requirements of the Mental Capacity Act 2005 (MCA). In addition, care plan assessments had not always reflected a person-centred approach to managing people’s care needs.

Following the comprehensive inspection in September 2015 and July 2016 the registered provider wrote to us and sent us an action plan saying how and when they intended to make the improvements needed to meet the regulations.

At the inspection in July 2016, we found that action had been taken to comply with the breaches of regulations with the exception of Regulation 12 (Safe care and treatment) because the registered provider had not protected people against the risks associated with the safe management of medication. Also in respect of Regulation 17 (Good Governance) as the quality monitoring systems were still not being fully effective in identifying risks

At the focused inspection on 7 November 2016 we found that some further actions had been taken to make the improvements stated in the action plan regarding medicines management and governance. However, the breaches of the two regulations had not been met in full. Although some breaches of the requirements of the regulations have been addressed, some remain. The service rating overall remains Requires Improvement.

The service did not have a registered manager in post at this inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and associated Regulations about how the service is run. At the time of the inspection in July 2016, there was a new manager in post but had not yet completed the process to register as a manager with CQC. They had left the post before our inspection on 7 November 2016 without completing registration.

A new manager has now been recruited and had been working in the home for a month when we inspected. We could see from audits and action plans the new manager had done that they were reviewing all that had been done so far to comply with the regulations and what still needed to be completed and embedded with staff. They demonstrated a clear understanding of the areas that must be addressed straight away and we could see that improvement work was underway. We saw that the lack of consistent and effective management during the time since the inspection in July 2016 had had a significant effect upon the service’s ability to implement and monitor improvements and to embed new practices and awareness with staff.

Westmorland Court Nursing and Residential Care Home (Westmorland Court) provides personal and nursing care for up to 48 people. Set in National Trust owned land the home is a short walk from the centre of the village of Arnside. There is parking available for visitors and a garden area for people living there to use. At the time of the inspection in November 2016 there 31 people living in the home. Twenty of the people were receiving nursing care and 11 were residential receiving personal care.

We found that that some improvements had been put in place since our previous inspection concerning quality assurance and monitoring processes. The policies and procedures for staff to follow had all been reviewed and updated and the new manager was monitoring staff practices. Since taking up the post the manager had being conducting ‘base line’ checks that were to form the basis of a full programme of audits and a monthly manager’s audit. The new manager was clear that a baseline was needed to monitor and measure development. The monitoring systems and quality management structures the new manager was implementing were only just starting and would need to continue to be used and evaluated to evidence consistency.

The new manager had done group and individual supervisions with staff to help to get to know them. The manager had also carried out observations of practice with them including moving and handling practices and hand hygiene. As a result they had identified that some staff had training needs that had to be addressed and this had been organised.

The new manager had been carrying out detailed medication checks themselves in the short time they had been in post. They had found that some procedures had not been followed by nursing staff and had held a nurse’s meeting to take staff through the correct procedures so they were all made aware of the shortfalls and of their professional responsibilities.

However, we found that medicines were still not handled safely. We saw that there had been improvements in some aspects of record keeping but these were insufficient to fully demonstrate that people consistently received their medication safely We found that some of the concerns were still on going from the previous inspection. The records about the amount of stock of people’s medication in the home were still not consistently accurate and did not always show that medication was accounted for or had been given as prescribed. The records about the administration of medication were also not consistently accurate.

We found that supporting information or ‘protocols’ were still not made clear to guide staff to administer medicines which were prescribed to be given “when required” or as a “variable dose”. Clear guidance is needed to help ensure people are given these medicines safely and consistently for such things as anxiety, constipation and sleeping. A small number of people were prescribed medicines to be used to prevent pain and other unpleasant symptoms that may occur during the end of life care. Care plans to guide nurses as to when these drugs should be commenced in order to help alleviate distress were still not yet in place.

We need to be confident that the registered provider can demonstrate consistent and improved practice over time. The registered provider has voluntarily suspended admissions to the home for a period of time, agreed with CQC, while the work still needed to fully meet the warning notices is completed. We will review our regulatory response and our ratings for safe and well led at the next inspection when the continuing breaches of regulations must be met.

We found the service, despite the improvements made, was still in breach of Regulation 12 Safe care and treatments (Management of medicines) and Regulation 17 Good governance. Where we have found continued breaches of the regulations we will ensure that action is taken.

This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk’

Following the inspection on 29 September 2015 we issued four requirement notices. These were in relation to the management of medicines and the procedures in use that did not reflect current national guidance for the safe management of medicines. Also the registered provider could not demonstrate that effective monitoring and communication systems were in operation to help identify and assess potential risks to people and their welfare. The registered provider had not made sure that all aspects of service provision and record keeping were being regularly monitored for effectiveness.

We also found that incidents that had occurred within the home that might affect people’s safety had not been appropriately referred to the local authority safeguarding team or notified to CQC.

We found at the last inspection that the registered provider had also not always acted in accordance with the requirements of the Mental Capacity Act 2005 (MCA). Also care plan assessments had not always reflected a person-centred approach to managing people’s care needs.

Following the inspection in September 2015 the registered provider wrote to us and sent us an action plan saying how and when they intended to make the improvements needed to meet the regulations.

At this inspection on 4 and 6 July 2016 there was a continuation of breaches of two regulations where requirement notices had been issued at the last inspection in September 2015. This was in respect of Regulation 17 (Good Governance) as the quality monitoring systems were still not being fully effective in identifying risks. It was also in respect of Regulation 12 (Safe care and treatment) because the registered provider had not protected people against the risks associated with the safe management of medication.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Following this inspection 4 and 6 July we asked for further information from the registered provider and manager and to provide reassurances on the immediate actions they were taking in regard to a safeguarding concern and the safe handling of medicines. This was to prevent any repetition of the concerns we had found and to mitigate any risks associated with the medicines management. This information was provided and on the second day of our inspection we saw that appropriate action had been taken to mitigate the immediate risks to people.

During this inspection we found a breach of Regulation 9 (Person centred care) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This shortfall was because people who used this service were not consistently having care or treatment that had been planned specifically for them.

We found during this comprehensive inspection that the home had made some improvements since the inspection in September 2015 in aspects of quality monitoring and had introduced an audit system. Improvements had been made to the care planning systems and an electronic care management system had been introduced to help consistency. The system was aimed at making care planning more person centred.

The registered provider now has procedures in place and staff were acting in accordance with the MCA. We found that consultation had taken place with people living at the home and relatives about the use of CCTV in communal areas. We saw that a private room had been made available for relatives if people wanted more privacy. Surveys and residents meetings were being used to get people’s feedback about the services being provided. Actions had been taken in response to feedback received. Appropriate policies and procedures had been developed regarding the use of CCTV in the home.

The service did not have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and associated Regulations about how the service is run. There was a new manager in post who had been appointed at the home following our last inspection in September 2015 but had not yet completed the process to register as manager with CQC.

Westmorland Court Nursing and Residential Home provides accommodation over three floors that are accessible by a passenger lift and bedrooms are for single occupancy. At the time of the inspection there were 36 people living at Westmorland Court.

We saw that the staff on duty approached people in a friendly and respectful way. People told us that the staff were “kind” and “caring”.

Care plans we looked at contained a nutritional assessment and a regular check was being done on people’s weight for changes. People told us the food in the home was “good” and that they had a choice of food and drinks.

The home had systems to check information when new staff were recruited and all staff had appropriate security checks before starting work. The staff we spoke with were aware of their responsibilities to protect people from harm or abuse and what action they should take should it ever occur.

There was a complaints procedure. People who lived at the home and relatives we asked were aware of it. All the staff we spoke with told us that they had regular meetings where they could discuss practice and concern. They confirmed they had formal supervision and said they felt they were supported in their work.

Training records indicated that care and nursing staff had received induction training and training relevant to their roles. Staff had also been able to attend training courses put on by a local hospice on supporting people at the end of life.

We saw that there had been some fluctuations in the permanent staffing levels in recent months. At present the manager was taking steps to try to maintain an adequate level of staff using agency staff and overtime. These would not feasible in the long term and can only be seen as a short term contingency and CQC will continue to monitor.

There were examples of poor practice around medication management in the home. This indicated that in these areas staff may not have fully understood the training and information provided. We recommended that the registered provider found out more about evaluating training for staff, based on current best practice and in relation to making sure staff understand and applied the training.

At this inspection we found that improvements had been made to the use of quality monitoring systems but these had not been fully effective. This was especially evident in the monitoring of medication management. There was still a lack of management oversight in some areas of practice and in checking daily records completed by the staff.

We found that there were few opportunities for people to participate in activities they enjoyed and organised activities in the home. The new manager was already taking steps to address this. Some bedrooms we visited did not have comfortable easy chairs in for people to use to spend time in their bedrooms. We recommended advice be taken from suitably qualified people on the provision of suitable seating for people with different needs and preferences for use in their private rooms.

The service rating overall remains Requires Improvement. Although some breaches of the requirements of the regulations have been addressed some still remain. We need to be confident that the registered provider can demonstrate consistent and improved practice over time.

You can see what action we told the provider to take at the back of the full version of the report.

We spoke with people who lived in the home in their rooms and in the communal areas of the building. We also spoke to a relative, staff who were on duty and a community nurse in private. Some of the people who lived in the home were not easily able to tell us their views about the home and the support they received. We used the Short Observation Framework for Inspection to assess how well the service met their needs.

We considered our inspection findings to answer questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

This is a summary of what we found -

Is the service safe?

People were safe living at Westmorland Court Nursing and Residential Home. The staff in the home were knowledgeable about the support people needed and had the skills to deliver the care they required. Care staff we spoke with showed that they had a good understanding of their responsibility to protect people who lived in the home.

Risks to people's safety and wellbeing had been identified and assessed and appropriate controls had been put in place to protect them.

The home had a range of equipment to support the people who lived there. We saw that all the equipment was serviced and checked regularly to ensure it was safe for people to use.

Robust systems were used when recruiting new staff to ensure they were suitable to be employed in the home.

The home had appropriate policies and procedures regarding The Mental Capacity Act 2005 deprivation of liberty safeguards. The manager of the home was knowledgeable about the Mental Capacity Act 2005 and the Mental Capacity Act Codes of Practice. This meant people could be confident that their rights would be protected.

Is the service effective?

People told us they received a good quality of care at Westmorland Court Nursing and Residential Home. They said the staff in the home knew the support they needed and how they wanted this to be provided.

We saw that the staff in the home treated people with respect. People were supported to carry out as much of their care as they could themselves, with the care staff assisting them with tasks they couldn't manage on their own. This supported people to maintain their independence and control over their lives.

Where people had been identified as at higher risk due to complex needs, appropriate specialist services had been contacted for advice and support.

The home had appropriate equipment to support people and to protect them from the risk of infection.

A member of the local community nursing service told us they had no concerns about how people were cared for at Westmorland Court Nursing and Residential Home. They said the staff in the home contacted them in a timely manner if a person required support and acted on any advice they gave.

We saw that there were sufficient staff to provide the care that people required. However we saw, and staff in the home told us, that there were occasions when the care staff did not have enough time to engage with people. The manager of the home had also identified a need for more staff and was recruiting additional staff to increase the number on duty at busy times.

Is the service caring?

Everyone we spoke with made positive comments about the staff employed at this home. One person told us, 'The staff are lovely' and another person said, 'The staff are very caring'. A visitor to the home told us, 'I think it's excellent here' and said, 'I've been very pleased, the home is better than I ever expected'.

We saw that the staff were kind and considerate in how they treated people. People were given choices about their lives and the support they received. We observed friendly and respectful interactions between the staff and people in the home.

Is the service responsive?

We saw that people were treated with respect and given choices about their daily lives. The staff were knowledgeable about people in the home and the support they needed. People received the support they required to meet their needs.

Some people needed small items of equipment to assist them to maintain their independence. The staff in the home knew the equipment individuals required and ensured this was provided as they needed it.

Thorough needs assessments were completed before people were offered accommodation in the home. This ensured that people were not offered accommodation unless the facilities and support provided were suitable to meet their needs.

Some care records had not been reviewed as detailed in the provider's policies. The manager of the home had identified that there were areas within the care records which required improvement. They were reviewing care planning procedures and had introduced more checks to ensure all the information in people's care plans was accurate and up to date.

Is the service well-led?

Formal systems were in place to audit the quality of the service provided. The manager of the home held meetings with people who lived there, their families and the staff employed, to gather their views about the service. We saw that action had been taken in response to the feedback given at these meetings.

The manager had been in post for five months at the time of our inspection. We saw that they had carried out a range of checks to assess the quality of the service provided. They had identified a number of areas which needed to be improved and had developed plans for how each issue was to be addressed. We saw that they had started to make the required improvements, giving priority to those areas important to maintain the standard of care and safety of people in the home.

Care staff we spoke with said the manager was committed to improving the quality of the service. One person said, 'I have faith in the manager' and another staff member said, 'The manager sets high expectations'.

The provider was required to have a registered manager in post, responsible for the day to day management of the home. The manager was in the process of applying to be registered.

People's care was planned very well and assessments were thorough and included personal information about people's care and welfare needs. People had a named advocate to act in their best interest if needed, for example a relative.

People commented, "I am well looked after, no complaints, the staff are really good". "I generally do most things myself, but I need to a little bit of help my personal care. There are plenty of activities to do but staff respect I don't want to join in them all'. A family member told us, "They always discuss his care with me, the least little problem. I would not move him anywhere else'.

People had care plans that promoted a person centred approach to their care. Staff were attentive to peoples' request for assistance and were respectful. Staff knew how to care for people at risk of falling, developing pressure ulcers or who may not eat enough.

People lived in a safe environment. They said they were comfortable and had everything they needed. There was sufficient staff on duty to make sure people had the attention they needed.

People were consulted in matters relating to their care and welfare. Quality assurance monitoring showed an overall satisfaction with the service provided, the staff team and the environment.

"Everyone does a wonderful job here."

" Whatever I need they give me, night or day."

We spoke to health and social care professionals about the home, they told us that:

"Everything's fine."

We found that the staff at the home always asked people for their consent before they did anything. We observed people being spoken to and cared for in a professional and courteous manner. The home ensured that people were free from harm and protected from abuse. We found that there was enough staff to meet people's needs and that the home had systems in place for monitoring the quality and standard of the service it delivered.