Westroyd Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service since it was registered under the new provider. This key question has been rated good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Systems and processes within the service were in place to support learning and sharing of information from incident and events, which included meetings involving the management team and staff. For example, a review and analysis of an incident had been undertaken by the registered manager where an emergency call bell had been activated in response to a person injuring themselves. The analysis and lessons learnt were shared with staff to reduce future incidents and promote safety.

Staff were clear any incidents or accidents would be recorded and a member of the management team informed. A member of staff told us, “We have post fall observations and look at the incident to see if anything needs changing, like footwear.”

The registered manager informed us an analysis of accidents and incidents was undertaken monthly and discussed to mitigate future risk or reoccurrence. Systems and processes supported the provider to have strategic oversight.

An external partner informed us the registered manager had implemented a new reporting system in recent months, which had provided greater reassurance that incidents and accidents were being responded to and being shared with partner agencies.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Some people spoke of making an informed decision to move from another service to Westroyd Care Home, and why, and how staff had supported them to settle into their new surroundings. A person said, “It was noisy in the last home, it was a good choice to move, it’s nice, it suits my taste”. Another person said, “I was in another home which I didn’t like. It’s much nicer here, the attitude of staff is much better, and they have helped me to settle in.”

Referrals for admission to the service were received via the local authority for those whose care would be funded, or direct from people or a family member.

Referrals were made in response to people’s changing needs to both health and social care agencies in a timely and effective way. This supported people’s continued care, including when people transferred to other care settings or hospital, and the sharing of information to support a smooth and safe transition. A social care professional told us, “A recent positive example was a person had moved in on respite care and wanted to make the placement permanent. Another person was receiving bariatric care, and the service were working closely with health colleagues and family to improve the person’s mobility.”

The registered manager informed us they considered the needs of people already in residence prior to accepting a new person into the service, to ensure compatibility with others along with ensuring the person’s cultural and religious needs could be met by staff.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People and their family members told us why they felt safe. A person told us, “I feel very safe, it’s the fact you know the staff are there.” A second person said, “I’m very safe yes, the staff look after me and no-one can get in.” A family member said, “My [person] is very safe. The carers regularly check up on them.”

All staff including staff employed to undertake maintenance and housekeeping confirmed they had completed safeguarding training and would report any concerns. A member of staff not directly employed to provide care told us, “Even though I don’t provide care, I still see the residents and know them well. If I had any worries, I’d report them to a manager.”

The registered manager informed us any safeguarding concerns were reported and investigated and where required the Duty of Candour was followed. The Duty of Candour requires health and social care professionals to be open and honest with people and their families where something goes wrong with their care and includes offering an apology.

Records showed the registered manager had undertaken safeguarding investigations when requested to so by the local authority. We reviewed the records of such an investigation, which evidenced the registered manager had spoken with the person who the safeguarding concern related to, their family member, and the staff involved. The person’s care records were also reviewed. The outcome of the investigation was shared with those involved, including external organisations.

Systems and processes were in place to document and monitor safeguarding concerns and Deprivation of Liberty Safeguards (DoLS), which were underpinned by policies and procedures. The provider shared concerns quickly and appropriately with statutory agencies in line with their responsibilities.

Evidence demonstrated any conditions linked to people’s DoLS had been actioned. In the absence of a relative or other appropriate person, people who had been deprived of their liberty under a DoLS, were visited by a Paid Relevant Person’s Representative (PRPR), who had been appointed to support and represent those individuals.

The provider worked with people to understand and manage risks. People’s records did not always provide consistent information as to how risks were to be mitigated and monitored.

Family members were aware of potential risks affecting their relative, including those at risk of malnutrition, and were aware, where appropriate, of equipment used to promote safety. A family member told us, “They involved me in the decision of using bed sides.” Another family member said, “We discussed having a walking frame, which was provided, and a pressure mat is now on the floor in response to them having fallen out of bed on one occasion.”

We found improvements were needed in the recording of people’s dietary and fluid intake where they were at risk of malnutrition or dehydration. For example, a person who often declined to eat had lost weight over a 3-month period. We found staff had not always recorded the food offered or the amount consumed. The registered manager told us the daily recommended fluid target for the person was 1200mls. Records showed the person often did not consume the recommended daily quantity of fluid. Referrals and tests had been undertaken by health care professionals to identify the cause of the weight loss, including the person’s reluctance to eat. The GP continued to monitor the weight loss through regular visits to the service. The person’s family member shared with us they were prescribed nutritional milk shakes, and they regularly visited to encourage and assist their relative to eat.

The registered manager informed us following our feedback staff had been given guidance to improve the quality of records, and that staff were now recording the food and fluid offered, as well as the amount consumed, for those identified at risk. Staff handovers included sharing information as to people’s food and fluid intake.

Risk assessments were regularly reviewed; however, the review was not always undertaken in a timely manner in response to a change in the person’s needs. For example, a person’s risk assessment for choking had been reviewed and scored, stating the person did not have any difficulties swallowing and they were able to feed themselves, independently and safely. However, other care records stated the person was at risk of choking, and at times required assistance with eating, and would store food in their mouth. This meant some assessments and risk assessments were not reflective of people’s current identified needs. Inconsistent information in people’s care records has the potential to place people at risk as staff have access to contradictory information as to a person’s needs. The registered manager acted and made the necessary changes to the person’s records. The person’s family member was aware of changes in their diet. They told us, “[Person] was on a soft diet in hospital, now they’re on solids and eating well.”

The provider’s systems for monitoring quality and safety had themselves identified inconsistencies in people’s care records, including records related to risk. These included nutritional risk scores for a person not being calculated correctly in response to their having lost weight. Action plans had been generated to bring about improvement, and progress continued to be made.

People’s care records provided information as to risk linked to health needs, for those living with diabetes, guidance was provided as to the signs and symptoms a person may display if their blood sugar levels were too high or too low. Potential risk linked to infection were included in care records for those who had a catheter.

Staff understood the assessment process and were aware of people’s needs and associated risk. They told us communication processes were good, and staff handovers were used, along with people’s care plans to ensure information as to people’s health and wellbeing was shared. Staff were able to describe people’s needs and highlighted individual risk to people, which included poor mobility, distressed behaviour, skin integrity and choking.

Staff told us they observed people and made sure they used their walking frames, that they had good fitting footwear and there were no trip hazards. Staff confirmed in the event a person fell, senior carers or the management team would review the event and identify if there were any changes needed to prevent repeated incidents.

The provider detected and controlled potential risks in the care environment. The provider identified where improvements were needed.

Family members described the service as being homely and friendly. A family member said, “It has a nice family feel about it.” However, some said the service looked tired. A family member said, “The home needs improving, it’s shabby, it’s run down.” Another family member said, “The place needs a bit of tender loving care.”

We received several comments from families about the driveway. A family member told us, “The drive is a nightmare.” Whilst another family member said of the driveway “They need to fix the potholes.” A monthly regional manager report of April 2025 had recorded ‘Driveway is uneven and in need of repair.’ Family member concerns about the condition of the driveway had also been documented in resident and relative meeting minutes. Temporary repairs had been made to potholes in October 2025. The provider was in the process of gathering quotes to improve the driveway.

The provider had a decoration and improvement plan, which was in progress. Some areas of the service had benefited from decoration, new flooring and furniture. The senior management team informed us; they had undertaken improvements to the décor and furnishings of the service since they had taken ownership 2 years ago and would continue to invest and make improvements.

Some family members spoke of the lounge being crowded, which they felt hindered visiting. A family member said, “There’s nowhere to sit when we visit, we feel we are intruding. It’s a bit unwelcoming, we feel we should stop visiting.” Another family member said, “The options to talk to [person] is limited, there’s nowhere for visitors to go privately.” The registered manager informed us that visitors had the option of sitting in the dining room, the quiet and smaller lounge, or their relative’s bedroom. A family member was aware of the alternative area they could use when visiting.

A person spoke positively of the person employed to maintain the service. They told us, “The maintenance man will do anything for you, he put a lot of family pictures up on my wall to make it more homely.”

Systems, including electrical and fire were maintained, and equipment used to support in the delivery of care, such as hoists was regularly checked for safety. Fire risks were assessed, and staff completed fire safety training.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People told us there were enough staff. A person said, “I use my call bell at night, I don’t wait very long.” A second person said, “I have a bell in my room, mostly staff are quite quick in coming. Staff are usually very prompt in getting the things I need.”

Family members views were mixed when asked if there were enough staff. A family member said, “There’s easily enough staff. There are always 4 or 5 carers about.” Another family member said, “My [person] gets assistance, but they can take a lot of time to assist them to go to the toilet, they have to hold it too long.” A family member told us, “There’s always staff in the lounge. If you want staff, they are always available.”

Staff were seen to respond to people’s needs in a timely manner, and we observed good relationships between staff and people throughout the day. Staff communicated well with people, referring to them by their preferred name, and answering any queries or questions posed. Staff told us the number of staff on duty and reduced following a decrease in the number of people the service supported. However, all staff said there were sufficient staff to ensure people were safe. The provider used a dependency tool to assess people’s individual and care needs, which was used to determine staffing levels.

Staff were recruited in a safe way. Appropriate checks were carried out prior to people commencing work, to enable the provider to be confident suitable staff with the right skills and experienced were employed.

We asked an external health care professional if staff had the knowledge to support people. They told us, “Yes, staff are well informed and demonstrate the knowledge required to support residents safely and effectively.”

Records showed staff had undertaken training in a range of topics related to health, safety and welfare, which enabled them to meet people’s needs. Staff were supported to attend training courses provided by the local authority and were encouraged to undertake vocational qualifications in care. A member of staff told us, “I have to do loads of training and refreshers. Obviously its good. Need to know how to do our jobs. Medicine training, moving and handling etc., very important.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People and family members spoke positively of the cleanliness of the service. A person told us, “It’s kept very clean and nice.” A second person said, “They keep my room lovely and clean.” A family member told us, “No concerns about cleanliness here, there are no malodours when I come.”

Staff had access to personal protective equipment (PPE), which included gloves and aprons. There were sufficient housekeeping staff on duty, who followed cleaning schedules in line with best practice guidance. Staff were knowledgeable as to how any infectious outbreaks within the service would be managed to promote the health and welfare of people and staff.

Audits and checks confirmed health and safety assessments, and ongoing monitoring procedures were in place. Cleaning schedules were in place, which were monitored for quality. A recent IPC audit and inspection had been undertaken by an external stakeholder, for which the service had scored 93% overall.

The provider did not always make sure that systems and processes for the management and monitoring of medicines and treatments were safe.

People told us staff provided support with their medicines. A person said, “I take medicine, staff always wait while I take it.” A second person said, “I have tablets three times a day, staff watch me take them.”

Improvements were needed to ensure some aspects of people’s medicines were managed safely. Some people received their medicine for pain relief via a transdermal (medicated adhesive) patch. However, medicine patches were not always applied in accordance with manufacturer’s instructions. This is important to prevent skin irritation when a patch is applied on the same area of the body. The area manager assured us they would review their system for managing the application and recording of transdermal patches.

We found MARs had not always been signed confirming topical medicines, such as creams and ointments had been administered. Guidance for topical medicines which were prescribed to be applied as and when required lack detail and guidance for staff. The regional manager report of October 2025 had identified gaps in MARs for topical medicines. The senior management team told us they were working with staff to bring about the necessary improvements.

The registered manager informed us when we visited that the last cohort of staff were completing their training for delegated health care tasks that day. Following our visit the registered confirmed all staff had completed the training. This included the application of transdermal patches, administration of insulin, eyedrops and the application of topical creams and ointments.

Some people’s medicine administration records (MARs) were handwritten. Where MARs are handwritten or altered, the provider had not always ensured they had been checked by a second member of staff for accuracy. For example, one person’s dose had been crossed out and amended from 1 tablet to 2 for lunchtime and at night. Staff had not recorded the reason around the change of dosage and the date this started.

Records showed people’s prescribed tablet and liquid medicine was being administered safely and on time. Medicines were stored safely. People were supported to have their medicines reviewed regularly by a health care professional.