Westbury Court 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 newly registered service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

Risks people faced were identified and assessed, but action to enhance safety was not always evidenced within care records or implemented in practice. Leaders told us there were enough staff to support people, but feedback from people, their relatives and staff, about the number of staff available was variable. There were not enough staff to effectively support people with their lunch on the first day of our inspection. People received their medicines as prescribed, but storage facilities did not always promote safe systems. People told us they felt safe at the service and staff were aware of their responsibilities to act on and report any allegation of abuse. The home was clean and well maintained and there were systems to prevent and minimise the risk of infection. There was a clear focus on learning from any accidents and incidents.

The service was in breach of the legal regulation relating to safe care and treatment.

This service scored 59 (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.

Records showed any accidents and incidents were fully investigated. This included discussing what had happened with those staff involved and asking them to reflect on the incident to improve their individual practice. Reflective practice sessions were held with the wider staff team, and incidents were discussed in staff meetings and staff supervision meetings. This ensured the required actions were taken to minimise risk of further occurrences.

Following the first day of our inspection, leaders took action to enhance staff’s knowledge of the Mental Capacity Act and the functionality of the electronic care planning system. This included disseminating capacity and decision-making guidance to the staff team, individual meetings with some staff and additional training sessions. Staff told us there was always learning after an incident and a staff meeting had been arranged following feedback of the inspection. One staff member told us, “There have been some issues and tension following the last CQC visit.”

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

Leaders assessed people’s needs before they were offered a placement at the service. This ensured the home was suitable for the person and enabled successful support to be provided.

Records demonstrated health and social care professionals supported safe systems and transitions. There were twice weekly telephone reviews by a doctor and pharmacist. Doctor’s visits were undertaken as needed. Staff told us they found it easy to call for advice between these calls, and referrals to specialist services were made in a timely manner.

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.

Prior to our inspection, staff had received training in a person’s health condition, but this did not include the complications which could occur. This had impacted on the person’s wellbeing and safety. Leaders told us this had been a distressing time for all concerned, and measures were immediately taken to minimise a reoccurrence. This included reflective practice and a review of staff training.

Staff had received training in safeguarding and knew their responsibilities to report any concerns. This included being observant and noticing any bruising or changes in a person’s mood. Staff told us they would check care records for possible explanations but would always report their concerns to leaders. Records showed leaders shared concerns quickly and appropriately with the relevant agencies.

People told us they felt safe at the home. One person told us, “I do feel safe here. The staff are fantastic.” Relatives confirmed they had no concerns about safety. One relative said, “I think they’re brilliant.”

The provider failed to 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.

For example, one person had fallen from their bed and sustained an injury, but there was no information in their care records about what action had been taken to minimise a reoccurrence. A staff member told us they presumed a crash mat was put in situ or their bed was lowered, but they were not sure. This did not ensure adequate action had been taken to ensure the person’s safety.

Other risks people faced had been identified and assessed, but the action to enhance safety was not always effectively monitored. For example, one record showed a person who was at risk of dehydration only drank 100mls in a day. Other days showed a low intake, but staff had not identified this. This meant they were not supported to prevent the risk of dehydration. One staff member told us they checked people’s fluid intake at the end of their shift, but this gave limited time to encourage a person to drink more if needed.

Some people required their bowel actions to be monitored, as they were unable to do this independently. Records did not show this had been completed. This meant the monitoring process was ineffective and increased the risk of people experiencing constipation and associated ill health.

People had their risk of skin damage assessed and some measures to promote safety were identified. However, some information lacked clarity and did not provide staff with clear guidance. This included sentences such as ‘Requires adequate nutrition and hydration to aid in maintaining good skin integrity.’ The records showed the equipment the person had in situ and the need to be repositioned to minimise the risk of skin damage. However, the monitoring records did not always show the person was repositioned in line with care plan guidance. This did not ensure consistency or adequate safeguards to enhance safety.

Another person was at risk of choking. Whilst the texture of the food and drink they required was stated, there was no other information to help staff ensure safety. This included interventions such as safe posture and the size of each spoonful to be offered to the person.

Care plans gave detailed information about promoting people’s independence. There was monthly analysis of any falls or wounds people experienced and their weight was regularly assessed. Records demonstrated specialist input from any professionals was requested as needed.

After the inspection, leaders told us they would investigate these shortfalls and provide additional training for staff as needed.

This is a breach of regulation 12, safe care and treatment.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment was spacious, well maintained and decorated to a good standard. People had the equipment they required including adjustable beds, pressure relieving mattresses and crash mats. There were handrails in the corridors and grab rails in bathrooms and toilets to support people with their mobility.

There were regular checks and servicing of equipment and environmental audits.

Each person had a Personal Emergency Evacuation Plan. This showed how the person would be evacuated if they had difficulties responding to the fire alarm or leaving the building unsupported in an emergency.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs.

Leaders used a dependency tool to assess the number of staff needed for each shift. They said they were overstaffed so they could ensure consistency at times of staff sickness or annual leave. However, people, relatives and staff raised concern about the number of staff available. Specific comments included, “This lot [staff] work really hard, they don’t stop. How they keep cheery, I just don’t know”, “My [family] feels care is rushed at times” and “This floor is often short especially for the level of people’s needs”. Staff told us staffing numbers often made it difficult to answer people’s call bells as quickly as they wanted to and mealtimes such as breakfast were rushed. One staff member told us they would like to see more staff supporting those people living with dementia as this would minimise boredom and associated behaviours.

On the first day of our inspection, people were not supported in a timely way. This meant people had a lengthy wait for their meal, which increased anxiety and frustration for some, and the risk of altercation. Leaders confirmed this was not usual practice, so asked us to observe lunch time provision the next day. On the second day, there were too many staff and the room was hectic, noisy and not calming. Staff did not recognise this, which showed a lack of understanding of people’s needs.

A range of online and face to face training sessions were arranged and many of these were deemed mandatory by the provider. Most staff had completed their required training, and reminders were sent to those who had subjects outstanding. Staff received one-to-one meetings with their line manager to discuss their work and staff meetings were held to keep everyone up to date with information.

Recruitment records demonstrated staff were usually safely recruited. However, one application did not demonstrate a full employment history, and another showed some gaps in the applicant’s employment. Both staff had worked with other more experienced staff and completed training and an assessment of their competence, before working on their own.

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.

All areas of the home were clean. Housekeeping staff told us they had enough staff and equipment to keep the home clean. We observed staff cleaning the communal lounges whilst people were having their lunch and wiping high touch points in the corridors.

Good infection prevention and control practice was followed. Personal protective equipment was in the bathrooms and people’s rooms, which made it easily accessible to staff.

Records showed staff had received training in infection prevention and control and regular audits were undertaken. Any shortfalls were immediately addressed or added to the home’s overall action plan. However, one relative felt staff’s training could be better. This was because they had seen a staff member use the same gloves for their relative’s personal care and the removal of their dentures. Other people and their relatives had no concerns. Specific comments included, “The home always looks clean and tidy. The cleaning staff seem to work very hard’ and “[Family member’s] room is clean. It’s dusted regularly and the carpet is cleaned. The home smells nice.”  

The provider did not always make sure that medicines and treatments were safe and
met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Feedback about medicines from people, their relatives and healthcare professionals was variable. One relative told us staff did not always ensure their relative swallowed their medicine before leaving or knew what the medicine was for. A health professional said people often ran out of their medicines, as staff did not identify stocks were running low. This meant if medicines could not be immediately dispensed, people were at risk of not receiving their medicines as prescribed.

Medicines were generally safely stored, but there was food and drink in 2 out of the 3 fridges which should only have been used to store medicines. Staff removed these items once identified. Staff had appropriately monitored the temperature of the clinical rooms which stored medicines. However, for those who had medicines in their own room, records did not show if the temperature of the room or cupboard was being monitored. This did not ensure consistency or accurate monitoring.

Records demonstrated some people were prescribed transdermal patches. However, the information did not always show staff rotated the site of patch in line with the manufacturer’s guidance. This increased the risk of the person experiencing skin sensitivity and irritation.