We carried out a review of the data available to us about Westholme Clinic Limited on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Westholme Clinic Limited, you can give feedback on this service.
Westholme Clinic is a nursing home that provides personal and nursing care for up to 55 people. At the time of inspection, 50 people were living at the service. People were aged 60 and over and lived with a range of health and physical health needs including degenerative conditions such as dementia.
The building is purpose built over two floors. The communal areas are on the ground floor. The building and garden were fully accessible, bedrooms on the first floor were accessed by a lift.
People’s experience of using this service
There was not an adequate process for ensuring care records were accurate and complete. The care records of some people did not show their nutritional intake had been appropriately assessed. Records did not always evidence how best interests decisions had been made. We found no evidence during this inspection that people had been impacted from these concerns and the provider took immediate action to address them.
The service was homely and welcoming, and people told us they felt safe. They said there were enough staff to look after them and they were listened to and treated with kindness. Systems were in place to protect people from the risk of abuse and improper treatment and staff knew how to identify potential harm and report concerns. People received their medicines safely from trained nurses
Staff provided personalised care. Positive and caring relationships had been developed between staff and people. People and their relatives spoke positively about staff and the care they received. People were treated with dignity and compassion by a kind, caring staff and management team who understood people's individual needs, choices and preferences well.
The service was led by a dedicated management team who demonstrated compassion and commitment to the needs of the people who used the service, and the staff who worked for them. The management team worked professionally with other agencies outside of the service and ensured a transparent, honest and open approach to their work.
People were cared for by staff who were well supported and had the right skills and knowledge to meet their needs effectively. Checks were carried out prior to staff starting work to ensure their suitability to work with people. People received support from a consistent staff team who knew them well. There were sufficient numbers of staff to ensure people did not feel rushed and people received their support on time.
People were supported to have maximum control over 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.
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 Good (report published 7 March 2017)
Why we inspected
This was a planned inspection based on the previous rating.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
The service had a registered manager in place. 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 our last inspection to the service in January 2016 we found two breaches of regulations. The provider did not have appropriate arrangements in place for the safe management of medicines. Also, the provider had not ensured the care and treatment of service users was appropriate, met their needs and reflected their preferences. We asked the provider to take action and the provider sent us an action plan in March 2016 which told us what action they would be taking. At this inspection we found that improvements had been made and these regulations were now met. At the last inspection, the service was rated “Requires Improvement” overall. At this inspection, we found that due to the many improvements made by the management team, the overall rating had improved to “Good.”
There was a system in place to ensure that medicines were managed safely. All staff authorised to administer medicines had received training and the competency of staff administering medicines was checked on a regular basis.
Each person had a plan of care which was person centred. Care plans contained information which was relevant to each individual and they provided staff with the information they needed to support people and meet their needs.
People told us they felt safe. Relatives told us they had no concerns about the safety of people. There were policies and procedures regarding the safeguarding of adults and staff knew what action to take if they thought anyone was at risk of harm.
There were sufficient numbers of staff employed to meet people’s needs. Risk assessments were in place to help keep people safe and these gave information for staff on the identified risk and guidance to mitigate the risks. Safe recruitment practices were followed and ensured only those suitable to work in care were employed.
The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found the manager understood when an application should be made and how to submit one. We found the provider was meeting the requirements of DoLS. The registered manager and staff were guided by the principles of the Mental Capacity Act 2005 (MCA) regarding best interests decisions should anyone be deemed to lack capacity.
Staff had undertaken training to ensure that they were able to meet people’s needs. The provider supported staff to obtain recognised qualifications such as National Vocational Qualifications (NVQ) or Health and Social Care Diplomas (These are work based awards that are achieved through assessment and training. To achieve these awards candidates must prove that they have the ability to carry out their job to the required standard). Trained nurse staff were supported to keep their skills up to date. All staff completed an induction before working unsupervised. Staff had completed mandatory training and were encouraged to undertake specialist training from accredited trainers. Staff received regular supervision and monitoring of staff performance was also undertaken through staff appraisals.
People received enough to eat and drink. People spoke positively of the food and the choice they were offered. We were told, “The food is good, there is always a choice”. People who were at risk of malnutrition were weighed on a monthly basis and referrals or advice on diet were sought from suitable professionals where and when needed.
Staff were knowledgeable about people’s health needs and knew how to respond if they observed a change in their well-being. Staff were kept up to date about people in their care by attending regular handover meetings each day. The home was supported by a range of health professionals and appropriate referrals were made for guidance or additional support.
People’s privacy and dignity was respected and staff had a caring attitude towards people. We saw staff smiled and laughed with people and offered support. There was a good rapport between people and staff.
Care plans reflected detailed information relevant to each individual and guidance for staff on how to meet people’s needs. The provider, registered manager and staff were responsive to people’s needs and the registered manager had introduced two programmes that provided meaningful support to help improve the quality of people’s lives at Westholme Clinic. People and their relatives spoke positively about the activities they were offered.
The provider had a clear complaints procedure and a copy was given to people and relatives when they moved into the home, there was also a copy of the complaints procedure on the notice board in the home.
The registered manager welcomed feedback on any aspect of the service. The staff team said communication between all staff at the home was good.
The provider had a policy and procedure for quality assurance. The registered manager operated an open door policy for both staff and people using the service and their relatives. Weekly and monthly checks were carried out to help monitor the quality of the service provided. There were regular staff, residents and relatives meetings and feedback was sought on the quality of the service provided through regular quality assurance questionnaires.
Following an inspection on the 10 and 13 February 2015 to Westholme Clinic Limited, breaches of legal requirements were found in six areas and we took enforcement action with regard to three of them. Warning Notices were issued in respect of care and welfare of people, management of medicines and assessing and monitoring the quality of service provision, which were to be met by 4 April 2015. A responsive inspection was carried out on 13 May 2015 to follow up on the warning notices. At that visit we found that improvements had been made and the Warning Notices had been met.
We undertook an unannounced comprehensive inspection of Westholme Clinic on 6 January 2016. This inspection was carried out to confirm that improvements had been sustained and to check that the service now met legal requirements in the breaches of the regulations we found in February 2015. At this inspection we found that improvements had been made and the service was no longer “inadequate.” However we have identified some areas for further improvement.
Westholme Clinic Limited provides personal and nursing care for older people living with dementia and other mental health conditions. It is registered to accommodate up to 55 people and at the time of our visit 50 people were living at the home.
The service had not had a registered manager in post since April 2015. The person currently managing the home had not yet been registered with the Care Quality Commission (CQC). We have referred to this person as ‘The manager’ throughout the report. 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’s medicines were not always managed safely. There were some medicines that were used as stock medicine for a number of different people. We found inconsistencies and poor practice in relation to medicines records, including transcribing of medicines and accuracy in recording medicines given. Staff were not fully aware of best practice guidance in relation to managing and recording medicines.
Before anyone moved into the home a needs assessment was carried out. However due to their needs, people did not always understand a care plan had been prepared for them. Only one relative said they were included in the development of their relative’s care plan. People’s care plans provided information for staff on how people should be supported. However care plans were task orientated and not person centred. There was little evidence that people were consulted and involved in the planning of their care so people were not always involved. This meant that care may not always be delivered in the way they preferred.
The manager used a needs dependency tool to assess the required staffing levels to meet people’s needs. People told us there were enough staff on duty. Relatives considered there were enough staff to meet people’s needs and we observed that there were sufficient staff on duty at the time of our visit.
People told us they felt safe. Relatives had no concerns about the safety of people. There were policies and procedures regarding the safeguarding of adults and staff knew what action to take if they thought anyone was at risk of harm. Appropriate recruitment checks were carried out to check staff were suitable to work with people.
Care records contained risk assessments to protect people from any identified risks and helped to keep them safe. Although these gave information for staff on the identified risk there was not always clear guidance on reduction measures contained in the risk assessment. There were also risk assessments for the building and contingency plans were in place to help keep people safe in the event of an unforeseen emergency such as fire or flood. We have made a recommendation regarding risk assessments.
Staff received training in a variety of subjects and the manager told us 80% of care staff had a national qualification in care such as a National Vocational Qualification (NVQ). Since the last inspection additional training has been provided for staff in areas such as caring for people living with dementia. The Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Newly appointed staff received an induction to prepare them for work and staff received regular supervision.
The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The manager and staff understood the basic principles of DoLS and acted in people’s best interests if they did not have capacity to consent to their care and support. However greater understanding of the Mental Capacity Act 2005 (MCA) and DoLS is needed. We have made a recommendation regarding MCA and DoLS.
People were satisfied with the food provided and said there was always enough to eat. People had a choice at meal times and were able to have drinks and snacks throughout the day and night. Specialist diets were catered for such softened food textures and consideration was given to certain conditions such as diabetes. The advice of specialist services such as the Speech and Language Therapist were sought so people could be supported to eat and drink safely and according to their needs.
Staff supported people to ensure their healthcare needs were met. People were registered with a GP of their choice and the manager and staff arranged regular health checks with GPs, specialist healthcare professionals, dentists and opticians. A visiting GP told us people’s health care needs were met and appropriate referrals were made when medical assessment or treatment was needed. Appropriate records were kept of any appointments with health care professionals
People told us the staff were kind and caring. Relatives had no concerns and said they were happy with the care and support their relatives received. Staff respected people’s privacy and dignity and staff had a caring attitude towards people.
People told us the manager and staff were approachable. Relatives said they could speak with the manager or staff at any time. The manager operated an open door policy and welcomed feedback on any aspect of the service. Regular meetings took place with staff, people and relatives.
The provider had a policy and procedure for quality assurance. The manager and senior staff carried out weekly and monthly checks to help to monitor the quality of the service provided. Quality assurance surveys were sent out to people and relatives at six monthly intervals to seek their views on the service provided by Westholme Clinic.
It was evident the manager and provider had invested time and effort into improving the service following the previous inspection. We noted improvements in all the areas identified during our previous inspections. Staff told us that the manager had made improvements to the service. They reported that the manager and provider had involved staff in discussions and decision making regarding improvements the service needed to make.
We two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. You can see what action we told the provider to take at the back of the full version of this report.
At the February 2015 inspection, breaches of legal requirements were found in six areas and we took enforcement action with regard to three of them. Warning notices were issued in respect of care and welfare of people, management of medicines and assessing and monitoring the quality of service provision, which were to be met by 4 April 2015.
We undertook this focused inspection to confirm that the service now met legal requirements as identified in the warning notices. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Westholme Clinic on our website at www.cqc.org.uk.
The service provides personal and nursing care for older people living with dementia and other mental health conditions. It is registered to accommodate up to 55 people and 35 people lived there at the time of our inspection. We were informed there had been changes to the management of the service. The registered manager, who was also the nominated individual, had resigned. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers and nominated individuals, 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 new manager had been appointed who was in day to day control of operations but had not yet registered with CQC.
We found that the warning notices had been met and that the provider was meeting legal requirements. We also observed improvements in the cleanliness and the decoration of the home, and saw that some furniture and equipment had been replaced.
Improvements had been made to people’s care and treatment records, particularly with regard to pressure area care and the treatment of people who have diabetes. Staff had clear guidance to follow to ensure people’s needs in these areas were met. We were also shown how the manager intended to redesign care plans to ensure they were more person centred and more appropriate for people living with dementia. However, we were unable to make judgements on them as they had not yet been fully implemented.
Improvements were made with regard to how medicines were managed. The manner in which medicines had been stored, recorded and administered had been improved. The treatment room was better organised so that medicines could be safely and securely stored. Records we looked at were up to date, in order and well kept. A system had been introduced where medicines were no longer left unattended when they were being administered.
A system for assessing and monitoring the quality of the service has also been introduced. This included weekly and monthly audits of the management of the service to ensure it was safe and met the needs of people. People, relatives and visitors told us that the newly appointed manager had a positive impact on the home and was responsible for leading the improvements that have been made.
The inspection took place on 3 and 10 February 2015 and was unannounced. At the last inspection in October 2014 the provider was in breach of Regulation 10, Assessing and monitoring the quality of service provision. This was a continued breach from a previous inspection in May 2014. The provider failed to meet their action plan following both inspections and had not made the necessary improvements at this inspection.
The service provides care and nursing care for older people living with dementia and other mental health conditions. It is registered for up to 55 people and 35 people lived there at the time of our inspection. There was a registered manager in place. The registered manager was also the nominated individual. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers and nominated individuals, 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’s safety was being compromised in a number of areas. The management of medicines was unsafe and we asked the provider and registered manager to take urgent action to rectify this. They notified us within the timescale that they had taken the necessary immediate action. The management of risks relating to people who were nursed in bed, at risk of pressure area damage and those with diabetes, was inadequate. This put people at risk of serious harm. Mental capacity assessments were not carried out; this meant people were at risk of receiving care and treatment that they had not consented to. Staff demonstrated kindness and compassion. However, their interventions with people were task focused and activities did not reflect people’s individual needs and preferences. Care plans lacked information about people’s specific needs and they were not kept up to date.
There was a complaints policy in place and a system to record and investigate complaints which we saw was being used. The provider carried out some audits, however these were not used to inform and implement improvement. The provider had given CQC an action plan stating what they would do to meet the requirements of the law. However, this was not being followed or monitored to reach compliance with the essential standards of safety and quality.
We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.
This inspection was carried out by one inspector and was unannounced. We observed care and support provided in the shared areas of the home. We checked a sample of people's bedrooms. We looked at records and files. We spoke with the owner and the registered manager.
This is a summary of what people told us and what we found.
Is the service safe?
Improvements had been made to ensure people were cared for and supported in premises that were adequately and safely maintained.
Is the service effective?
The provider was taking steps to ensure people were cared for and supported in an environment which took into account published guidance on supporting people to live well with dementia. Adaptations were in progress to support people's independence, provide memory cues and improve the standard of decoration.
Is the service well led?
The provider did not have an effective system of internal checks and audits to maintain the quality of service provided. Examples of poor practice were not identified and corrected.
This is a summary of what people told us and what we found. If you wish to see the evidence supporting our summary please read the full report.
Is the service safe?
People's relatives told us they were satisfied their loved ones were safe and supported by caring staff. One visitor said, 'The carers are great.' We saw interactions between staff and people who used the service which showed staff were attentive to people's safety and welfare.
We found the service had systems in place to ensure people were protected from the risk of abuse. They carried out the necessary checks before staff started work and there was a robust recruitment process in place. There were sufficient staff to provide care and support that met people's needs.
However, we found incomplete repair works meant people were not fully protected against the risk of the spread of infection.
Is the service effective?
People's relatives told us their family members received effective care which took people's preferences into account. Two relatives said they had seen improvements in their loved one since they had been using the service. One relative considered the service could do more to communicate with them about their family member's status.
We found systems were in place to ensure care was delivered according to people's plans. People's care and support were based on thorough assessments and detailed support plans.
However we found instances where the service was not following published guidance in supporting people to live well with dementia.
Is the service caring?
Relatives of people using the service told us support was provided in a caring way. One said, 'You cannot fault the care workers.' Another said the staff were 'magic'. We saw a written comment that 'All the staff are very caring and do a difficult job very well.'
Staff we spoke with were motivated to provide high quality care. They had a thorough knowledge of people's needs and how they preferred to have their care delivered. We observed care and support that were delivered in a way that was mindful of people's comfort and welfare.
Is the service responsive?
People's relatives told us they had been involved in their family member's assessment and care planning, and that their views and preferences were taken into account. The service responded to changes in people's needs and circumstances.
We found the service had systems in place to ensure the care provided was appropriate to peoples' changing needs.
Is the service well-led?
Staff told us they were supported to deliver high quality care and they were able to contact somebody for advice if they needed to. They said if they raised concerns with the manager, they were confident they would be dealt with appropriately.
Systems were in place to regularly assess and monitor the quality of service provided. Risks were assessed and appropriate action plans were in place. There were processes in place to review and learn from incidents, accidents and complaints.
However, the system of internal checks and audits was not effective in identifying deficiencies in people's care and support.
We spoke with four members of staff who told us they felt confident in their role. They said that they had regular training and felt very supported by the manager. During our observation we saw that staff interacted well with people when they were supporting them. We saw that staff were knowledgeable about people's needs and preferences. We found staff were respectful and maintained people's dignity, privacy and independence. For example staff worked at the person's pace and noted body language and emotions to lead them in their care of those that could not communicate their needs or preferences.
We were shown examples of person centred care records which were well organised into separate sections. A relative's assistance was sought with this where the person was unable to fully contribute themselves.
Equality and diversity had been considered in the service by looking at each individual's needs. Any equipment or adaptations needed were provided.
People living at the home told us that staff were kind and respectful towards them. One person said, "they [the staff] are very polite." Another person said, "they [the staff] are as good as gold." People told us they had choice in their daily activities and care. People told us that they or their family members were included in care planning. One person said that the staff understood their needs and that "they listen." One family member appreciated that the staff involve them in care issues related to their family member, "they know exactly what's up and tell me everything."
People told us that they felt safe living at the home and that staff were responsive to any concerns. One person said, "they respond immediately." Another person said, "give it to [the manager] and she'll sort it." People told us there was always enough staff available to assist and people did not have to wait long to receive support with their needs.
Using the SOFI tool, we observed staff supporting people in a positive way that support people's dignity and independence.