Westbourne House

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. At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment and staffing.
 

This service scored 38 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Effective systems did not ensure learning from accidents and incidents were taking place. Although the service did have a monitoring process to collate information about accidents and incidents, we found that incidents had been documented which had not been included in this monitoring and there was no evidence of learning from incidents or that steps had been taken to mitigate future risks.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. Feedback from professionals highlighted whilst the service was approachable and keen to engage, issues with organisation at the service had resulted in people missing appointments. Records did not evidence that professional advice was always followed, for example a professional had requested the service contact a person’s GP regarding medication concerns. There was no evidence this had taken place and we could not be assured this information was shared with the correct professional.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. Risks associated with people’s safe care and treatment were not always recognised and reported by the service. Safety issues relating to medicines administration, environmental safety and governance were found during the assessment. Although the majority of staff had completed safeguarding training, the service had not ensured sufficient was in place to identify and address risks quickly.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found where required, appropriate referrals to the local authority were made and the service was compliant with this element of the act.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. We found that some specific areas of concern highlighted at the services previous assessment had been addressed however the service had not been proactive at identifying where risk existed within the service and addressing this. For example, the care plan for a person with epilepsy did not contain information about how to identify the possible types of seizure the person may experience, what to do if a seizure occurred or who to contact and when. Epilepsy training for around half of the staff team was overdue and there was no evidence the service had recognised this as a risk or had attempted to address this.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. The service had not worked proactively to ensure the care environment was safe. There was a lack of understanding of roles and responsibility in relation to building safety. The services electrical safety certificate was 6 months overdue and there was no evidence to indicate effective systems were in place to monitor the safety of the environment. Concerns had been raised previously with the service from both the fire service and CQC regarding the ability to safely evacuate the building in the event of a fire. The service was routinely staffed by one member of staff during the night. The provider could not demonstrate that a single member of staff would be able to safely evacuate people from the building within appropriate timescales in the event of a fire. The fire service had raised these concerns with the provider in June 2024 and again in February 2026. However, the provider had not taken sufficient action to address the identified risks. The service had also been informed previously by the fire service that a stairlift in situ may impede evacuation from the building. There was no evidence of work undertaken to address these concerns. Following the assessment the provider took some immediate actions to address safety within the service, including increasing staffing numbers, arranging a fire risk assessment making arrangements to obtain an electrical safety certificate for the building.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs. Staff at the service were kind and caring however staffing numbers in place at the time of the assessment had not ensured that care could be delivered safely. Despite previous concerns being raised regarding the number of staff on duty the service had not ensured a safe level of staff were on shift to manage the risks associated with lone working and fire evacuation. Some areas of staff training were overdue. There was no evidence of a plan to address this at the time of the assessment. Following the assessment steps were taken by the service to increase staffing numbers and increase staff training rates.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Whilst some areas of the home were clean and staff were observed to actively clean the service, some areas for improvement were identified. Environmental issues within the service meant some areas and equipment could not be effectively cleaned, increasing the risk of poor infection prevention and control. For example, a shower chair had areas of rust damage and visible dirt underneath. In the kitchen, damaged surfaces prevented effective cleaning. The sealant around a worktop was loose and visibly soiled, and the worktop itself was damaged.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We could not be assured that medicines were managed safely. Where people received variable dose medication, staff had not recorded the dose of medicines administered. This meant that records did not demonstrate how much medication people had taken. People prescribed ‘as required’ (PRN) medicines did not always have detailed protocols in place to ensure staff would know when to give these appropriately. For example, a protocol relating to a variable dose medicine did not indicate to staff when to give a higher or lower dose. Staff did not regularly record if PRN medicines given had been effective. Where the service had identified issues with the management of people’s medicines, these concerns had not always been shared with the appropriate professionals in a timely manner. Some medicines administration records contained missing entries with no explanation, so it was unclear if people’s medicines had been administered or not, and if not the reason for this. We could not be assured that medicines requiring disposal within a specified timescale were managed safely. For example, one person had been prescribed a liquid medicine that should have been discarded within 3 months of opening. The date the medicine was opened had not been recorded, so staff could not demonstrate the medicine remained within its recommended period of use. This meant there was a risk the person could receive medicine that was no longer suitable for use. Medicines audits that took place at the service were not effective at identifying and addressing these concerns.