Westbourne House

Date of assessment: 9 June 2026 to 30 June 2026. Westbourne House is a residential care home, providing support to people of varying ages, some of whom with a physical disability, mental health conditions or dementia. At the time of our inspection 10 people were using the service. At our last assessment we rated the service inadequate, we also took enforcement action against the provider. We were previously concerned about medicines management, managing risks posed to people, fire safety, staffing and governance. We carried out this assessment to check if the provider had made the required improvements.

We found the provider remained in breach of regulations. Whilst we found some improvements had been made, for example specific concerns relating to choking risks had been mitigated. However, we found some continued concerns relating to managing risks posed to people, staffing, governance, medicines and fire safety. The provider had not made the required improvements following the previous inspection and we found further concerns at this inspection. The service continues to be rated inadequate, and the service remains in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a time frame within which providers must improve the quality of the care they provide.

The provider was not managing medicines safely. Audits to manage medicines were not completed effectively to ensure risks could be identified and acted upon. Care plans did not always contain sufficient information to support the management of people’s specific health conditions, and some plans contained information which was contradictory. The service did not have sufficient staff to safely evacuate the service through the night.

The service did not have effective governance systems in place. Management oversight tools such as daily walkarounds were not completed consistently and accidents and incident monitoring was ineffective as not all incidents were considered as part of the analysis. Roles and responsibilities were not established within the management team and there was a lack of oversight of the service.

Recruitment was completed safely and staff were observed to be warm, kind and caring towards the people they supported.

It is noted that following the assessment the service has engaged with support and has undertaken some immediate actions to address concerns raised. This includes increasing staffing levels at night time to reduce the risks associated with evacuating the building in the event of an emergency.

Date of assessment: 4 February 2026. Westbourne House is a residential care home, providing support to people of varying ages, some of whom with a physical disability, mental health conditions or dementia. At the time of our inspection 7 people were using the service. At our last assessment we rated the service requires improvement, we also took enforcement action against the provider. We were previously concerned about medicines management, managing risks posed to people, environmental risks, staffing and governance. We carried out this assessment to check if the provider had made the required improvements.

We found the provider remained in breach of regulations. Whilst we found some improvements had been made to the environment and medicines management, we found some continued concerns relating to managing risks posed to people, staffing, governance, and some remaining environmental concerns. The provider had not made the required improvements following the previous inspection and we found further concerns at this inspection. The service is now rated inadequate, and the service has been placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a time frame within which providers must improve the quality of the care they provide.

People were not always supported by enough staff, and lone-working and on-call arrangements were not consistently effective. People were not always protected from avoidable harm. Staff did not always provide food to people in line with their assessed needs, and seizure monitoring concerns from our previous assessment had not been addressed.The provider did not appropriately address fire safety hazards. Safeguarding processes were not always effective. The service was not consistently applying the Mental Capacity Act 2005. Although DoLS authorisations were in place, capacity assessments for key decisions were not undertaken. Incident reporting systems were inconsistent. Some improvements had been made in infection control, refurbishment, and some aspects of medicines management. However, medicines storage remained a concern. Recruitment was safe, but delays in refresher training meant the provider could not evidence staff had the skills needed to support people safely. Working and on-call arrangements were not consistently effective. People were not always protected from avoidable harm.

Some care plans and risk assessments often lacked sufficient detail to guide staff safely about people’s mental and physical health conditions.However, people’s preferences and life history was included in their care plans. Whilst we found people had input from external professionals to manage their health needs, we could not be assured staff provided evidenced based support to people due to concerns we found relating to risk management and a lack of staff refresher training.

Governance systems were not effective in identifying and actioning concerns we found. Whilst audits had been introduced since our last assessment, these failed to recognise concerns we found, and not all issues we found at our last assessment had been addressed. Staff told us they felt supported in their roles and staff received regular supervisions.

Date of assessment: 2 to 5 September 2025. Westbourne House is a residential care home providing support to people of varying ages, some with a physical disability, mental health conditions or dementia. At the time of our inspection 10 people were using the service. This assessment was undertaken to give the service their first rating. Improvements were required to ensure the service operated safely. We found concerns relating to managing risks and risks from the environment. We could not be assured people were supported by enough staff and medicines were not always safely managed. The provider did not always control and manage the risk of infections. We found concerns relating to the leadership and governance of the service. Several areas of the home required refurbishments and decoration. Some care records needed improvement to ensure they included sufficient information, clear guidance for staff, and a full assessment of risks posed to people. Staff were recruited safely, trained and received regular supervisions. Staff told us they felt supported by the management team and worked well together as a team. We identified breaches of regulation in relation to managing medicines, governance, premises and equipment, infection control, staffing, and managing risks. The service is now rated inadequate in safe and requires improvement overall.