Westfield Rest 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. At our last assessment we rated this key question good. At this assessment the rating has changed to 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.

The service was in breach of legal regulation in relation 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 did not always have a proactive culture of safety. Lessons were not always learnt to continually identify and embed good practice. We identified significant shortfalls in relation to continually learning lessons. For example, audits did not support learning. They had not always identified if changes were needed to help ensure the safe management of medicines and the safety of facilities and equipment. Additionally, when expert advice was given in relation to some facilities and equipment, this was not followed.

However, staff we spoke with knew how to report individual accidents and incidents and why this should be done. Staff told us if changes were needed to people’s care, this was shared through handovers and discussions, and investigations were carried out in relation to some areas of practice to identify if there were any lessons learned.

Accident and incident forms were completed and the administration manager told us these were reviewed to identify any themes or trends. For example, a sensor mat and fall impact mat had been included in a person’s care plan as they sometimes rolled out of bed. This meant staff were alerted if the person rolled out of bed and the fall impact mat protected them from hard surfaces. This minimised some risks.

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.

Prior to people moving into the service, a pre-admission assessment was carried out to ensure the service could meet people’s needs. People told us if they needed support from a health professional, this was arranged and documentation we saw evidenced this.

Information was provided to health professionals to inform clinical decision making. For example, if a person needed to go to hospital in an emergency, written information was provided. This helped communicate essential information to staff who may be unfamiliar with the person’s needs.

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 told us they felt safe. One person commented, “I don’t have to worry about anything.” Staff were able to confidently explain the reasons they may make a safeguarding referral to the safeguarding authority and how they would do this.

Deprivation of Liberty Safeguards (DoLS) applications were submitted appropriately. Mental capacity assessments were carried out and best interest meetings and discussions were documented. This helped ensure any restrictions were lawful.

The provider worked with people to understand and manage the individual risks they faced by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were in place to identify if people were at risk of falls, malnutrition and to assess the risk of people developing pressure damage to their skin. These were reviewed when required and risk controls were in place if needed. For example, we saw one person used a stick to walk. The registered manager told us they had noticed the person was not using their frame and shared with the manager this was because they didn’t like it. The registered manager arranged an assessment by a health professional, and a stick was prescribed to support the person’s mobility and wishes. The person told us staff reminded them to use their stick to support their safety. Another person had been supported to manage the risk of slipping from a chair. The registered manager had involved other appropriate health professionals, and a specialist chair was obtained. This minimised the risk of avoidable harm and supported the person’s comfort.

The provider did not always detect and control potential risks in the care environment. There were significant shortfalls with regard to equipment and facilities provided.

Equipment was not always serviced to help ensure it was safe to use. Two items of mobility equipment which were in use had not been serviced in accordance with Lifting Operations and Lifting Equipment Regulations 1998. In addition, we found work to ensure the electrical system was safe had been identified as being required 8 months previously. Work to ensure the system was safe had not been completed at the time of the assessment. We discussed our concerns with the registered manager, and the work was completed prior to the assessment concluding.

A radiator in a bathroom which could be accessed by people, had no cover and was hot to touch. This posed the risk of scalds. Wardrobes were not fixed to walls and were able to be moved which posed the risk of accidental injury if they fell over. There were no risk assessments completed to assess the risk of this to individuals.

Two windows in one room did not have tamperproof window restrictors and could be opened wide. There was no risk assessment to show this was sufficient to minimise the risk unauthorised people could access the home. In addition, we saw the garden gate was open and had no lock fitted, this meant the garden area could be accessed by unauthorised persons.

We discussed our concerns with the registered manager. Prior to the assessment concluding we received some written assurances that action was being taken to resolve the issues we discussed.

The provider was making improvements to the fire safety controls at the service; we saw work was being carried out to ensure all relevant fire regulations were met.

The provider did not always ensure there were enough qualified, skilled and experienced staff. They worked together well to provide safe care that met people’s individual needs.

Staff had access to evacuation chairs. These are chairs that are used to move people on stairs if there is an emergency and the lift cannot be used. The registered manager told us staff had not had training in these and staff confirmed this. The registered manager said they were seeking training to support safe evacuation processes.

The provider used a dependency tool to help assess the number of staff required to support people. People were supported quickly when they needed help and staff chatted to people and spent time with them. People were not rushed and staff enabled people to walk at their own pace and were patient with them.

The provider followed recruitment procedures to ensure all required checks were completed before staff started work at the service. Enhanced Disclosure and Barring Service (DBS) checks were carried out. DBS checks provide information about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

Staff had regular training, and an induction was in place to support staff who were new to the service. One staff member commented, “They supported me well.” Staff had regular supervision and appraisals. They said these were useful and enabled them to discuss training, their performance, and any concerns they had. They told us this was a supportive process which enabled them to spend time with management on a one-to-one basis.

The provider managed the risk of infection. They were working closely with the local infection prevention and control team to help ensure that best practice was followed.

For example, the registered manager said they had explored the idea of using commode liners with the local infection prevention team. The registered manager said they were planning to convert an outside area into a sluice as soon as possible.

The kitchen where food was stored, prepared and cooked was clean and there was a cleaning schedule to ensure it remained in a satisfactory condition.

People were happy with the standards of cleanliness at the home. One person told us, “It’s very clean, they’re always cleaning.” Bedrooms and communal areas were clean and we spoke with a housekeeper who told us they had a cleaning routine to follow which helped ensure the environment was hygienic.

Staff had access to personal protective equipment, and we observed staff using this appropriately.

The provider did not always make sure that medicines and treatments were stored securely, and medicines were not always available if needed. There were shortfalls with regard to the safe management of medicines.

Medicines were not always stored safely. One medicine trolley which contained prescribed medicines was in a communal corridor and was not fixed to the wall or locked away. There was no secure storage for medicines which were required to be kept in a fridge. We saw an unlocked container which contained a prescribed cream. This posed the risk that medicines that required cold storage could be accessed by staff who were not trained in the administration of medicines.

One medication record recorded a medicine was out of stock for 23 days. We discussed this with the registered manager who investigated this. They told us the medicine had been discontinued before Christmas 2025 and the entry of out of stock was incorrect. This had not been identified by the staff administering the medication or audits completed.

We also noted not all medicine administration records (MARS) had been double signed by staff, when they had been handwritten. Handwritten medicine records should be signed by two staff to help prevent the risk of medication errors.

Medicines were dated on opening to ensure any medicine with a short shelf life could be identified and disposed of when it had passed its expiration date. Medicine records were completed to support medicines being given as prescribed.

Medicines were disposed of safely and staff had received training in the safe management of medicines. Competency assessments were carried out to ensure staff were competent. We observed medicines being administered in a discreet and safe way.