Boston West Care

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 Good. This meant people were safe and protected from avoidable harm.

This service scored 62 (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, investigated them, and reported any safety events. However, systems and processes to enable learning and to embed good practice needed strengthening.

Incident monitoring records reviewed between April and September 2025 confirmed staff were recording and reporting accidents and incidents, including falls. Monthly and 3 monthly analyses were completed to identify themes, patterns and trends. Whilst records confirmed immediate actions were taken such as first aid, medical attention and advice sought, there was limited evidence of investigations to consider the possible cause and actions to reduce recurrence and learning being shared with staff.

Incident records highlighted behavioural incidents involving an individual towards others. While there was documented evidence that these incidents were shared with the local authority and commissioners, there was limited evidence to demonstrate that lessons were learned and embedded within staff practice. Specifically, there was a lack of clear actions or training to support staff in safely managing similar behaviours and reducing the likelihood of recurrence.

The manager had recently introduced new and improved communication systems and processes. This included daily meetings with staff, where incident management was discussed, including any actions and lessons learned. These new procedures needed further time to fully embed and be sustained.

The provider had a complaint policy and procedure. Upon reviewing the complaint folder, we found a lack of effective analysis, such as themes, patterns and trends and learning from complaints to support service development. We discussed this with the manager, who agreed that improvements were required.

Relatives told us they were informed of any incidents and accidents. A relative said, “If there's been any incidents or anything that I need to be aware of, I'm always contacted and informed in good time.”

Feedback from external health professionals confirmed that any medication errors or incidents were reported. Comments included, “The home are good at escalating and being open and ask for advice if there are any medication errors and seek support for this.”

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. However, concerns were identified about an inappropriate placement, which had a negative impact, putting other people at risk and the person at risk. This person was no longer living at the service.

The provider’s pre-assessment process at the time had not been sufficiently robust to ensure this person’s individual needs could be appropriately supported. The manager told us they were concerned that there had not been a thorough pre-assessment to ensure this person’s needs and safety, as well as that of others, could be met. This shortfall in planning had put people at risk and ultimately led to a breakdown in the placement, which could have had a detrimental impact on the person involved.

The current manager, who was not in post at the time of the admission, acknowledged that the placement had been inappropriate and assured us that such decisions would not be repeated. They gave a recent example where a referral was declined after an assessment determined that the individual’s needs and the safety of others could not be adequately supported. While this response provided some assurance regarding improved decision-making processes, there was insufficient evidence to make an informed judgment at the time of this inspection. No recent permanent placements for people with complex care and treatment needs had been made.

The provider had systems and processes to share important information with others such as ambulance and hospital staff to support consistency and continuity of care.

A relative confirmed the pre-assessment and transition arrangement for their family member was a positive experience. They said, “The assessment and transition process were organised, I was engaged every step of the way.”

Feedback from external healthcare professionals told us communication and ways of working with the service, had been difficult at times, however some improvements had been made recently and were ongoing.

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. However, the provider had not always shared concerns quickly and appropriately.

From reviewing incident records, we identified not all safeguarding incidents reported to the local authority had been notified to us, CQC. Following our inspection, the provider submitted these notifications. The manager told us that the lack of reporting to CQC was an oversight and apologised, assuring us that they had learnt from this.

The provider had safeguarding and whistle blowing procedures and staff confirmed they were aware of them. Staff received refresher safeguarding training and demonstrated an understanding of their role and responsibilities in protecting people from abuse and avoidable harm.

Relatives told us they felt confident their family member was safely cared for. A relative said, “We have no concerns about safety. [Name] is definitely well cared for.” Another relative said, “[Name] can be verbally aggressive at times, but staff will smile and give assurance, they are just amazing.”

The provider worked with people to understand and manage risks 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. However, people’s care plans and risk assessments were found to not consistently reflect people’s current care and treatment needs. The provider had already identified this, and their action plan recorded all care plans and risk assessments were due to be reviewed and updated by 31 October 2025. This work had commenced.

We found the nursing and care staff knowledgeable about people’s care and treatment needs and any risks associated with their health conditions. We therefore concluded this was a recording issue and found no evidence of impact on people.

Some people were living with dementia and or a mental health need that impacted their emotional wellbeing and behaviours at times. Care plans and crisis plans provided staff with helpful guidance, outlining potential triggers and strategies to support the person safely and effectively. However, this information needed to be reviewed to ensure it remained up to date and relevant. The manager confirmed these were also due to be reviewed. Daily monitoring records demonstrated how emotional needs were being tracked and managed, providing valuable insight to external professionals in ongoing assessments of people’s care needs.

Relatives told us they were confident staff understood any risks related to their family member’s care and treatment, and these were managed safely. A relative said, “[Name] has had a stroke, they can display some behaviours at times, staff understand their needs well and are patient and supportive.”

Whilst relatives were positive about being involved and consulted in their family member’s care, there was no formal review process that involved people and relatives or representatives. However, the manager had recently introduced a ‘resident of the day’ review, which included a documented discussion with the person and their next of kin or representative.

We observed how people were supported with lifestyle choices. For example, when people choose to smoke, this was risk-assessed, and support was provided to manage this safely for the person and others.

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

Our observations of a sample of wardrobes in people’s bedrooms found they were not secured to the wall, presenting a potential safety hazard. Additionally, our observations identified other potential environmental risks, including an unlocked sluice room and fuse box cupboard. Some of the inlays in the drain covers within the courtyard were lifting at the corners, creating a potential trip hazard. These issues were raised with the manager, and immediate actions were taken.

At the time of the inspection, only ground-floor bedrooms were in use. The first and upper floors were undergoing building work and were therefore not accessible to people using the service.

The provider had relevant health and safety policies and procedures to ensure the service, premises and equipment were serviced, maintained and monitored. This included a daily walk around that included visual checks on health and safety, any shortfalls were recorded and action taken. Clinical equipment was checked and serviced to ensure it remained easily available and in working order.

Risks related to fire safety and legionella, a waterborne bacterium that can cause serious illness, were assessed, mitigated, and monitored. Staff had received fire safety-related training. The fire service had recently undergone an audit. Overall, they were satisfied with the fire safety measures in place. Where recommendations had been made, these had been addressed.

Personal emergency evacuation plans were held electronically and printed during the inspection to facilitate easy access if people needed support in evacuating the building.

The premises were secure. A fence had been erected to provide privacy and security from a house within the grounds that belonged to the provider but was privately occupied. People had access to a courtyard with a smoking shelter, seating, sun protection and pleasant flower borders. We observed this being used by people.

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.

There were sufficient numbers of experienced staff in place at the time of the inspection. The provider used a dependency tool to help determine appropriate staffing levels based on individuals’ care and treatment needs. Our findings confirmed that staffing levels were adequate to meet those needs.

Staff deployment had been thoughtfully assessed, including the implementation of a twilight shift with 1 additional care staff member on site between 5pm and 11pm. This arrangement considered the needs of individuals living with dementia, particularly those who may experience sundowning, a pattern of increased confusion, agitation, anxiety, or disorientation that can occur during the late afternoon, evening, or night.

Staff received ongoing training. The training matrix showed overall good compliance. A broad range of training had been delivered to ensure staff were equipped to meet the diverse needs of people using the service. Nursing staff completed an annual refresher clinical training. Competency assessments for care staff and clinical competencies for nurses were actively being completed. The manager outlined plans to further enhance staff development by introducing more role-specific training and increasing opportunities for face-to-face learning.

At the time of the inspection, the clinical lead position was vacant. Clinical supervision, oversight and leadership were being provided by the clinical lead from the provider’s additional nursing home. They attended the service every fortnight for 3 days, and communication systems and processes were in place to always provide support and guidance.

The provider completed checks with the Nursing and Midwifery Council to confirm nurses were registered and eligible to practise.

Staff were recruited safely. Appropriate checks were carried out before employment, and only suitable staff with the right skills and experience were employed. Induction training was provided to new staff and this included ‘shadowing’ experienced staff.

Staff supervision and appraisal information indicated that this was an area where the manager was making improvements.

Staff were positive about working for the provider and felt well supported, enabling them to provide effective care. A staff member said, “Training is online with some face-to-face. I completed an induction, shadow shifts, and had a buddy. I feel well supported.

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.

The local authority's infection prevention and control team completed an audit in July 2025. The service was found to be compliant.

The provider had an up-to-date infection prevention and control policy, and staff had received relevant training. Areas of the service were visibly clean and hygienic. Staff had access to personal protective equipment, and safe waste management practices were in place. Domestic staff followed cleaning schedules aligned with best practice guidance, and a review of these confirmed that daily and deep cleaning were being completed.

Checks were also routinely completed on mattresses and pressure-relieving cushions, not only to check for safety but also for cleanliness and hygiene. A sample check of mattresses and pressure-relieving cushions found no concerns.

Relatives were positive about the cleanliness and hygiene of the service. A relative said, “I've always found the service to be spotless and never any odours.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were ordered, stored, managed, and returned safely. We saw medicine administration record (MAR) charts were in place and had been completed accurately, showing people had received their prescribed medicines when required.

When people were prescribed medicines ‘as and when required’ (PRN), protocols were in place to guide staff on when to administer these medicines. Staff recorded when and why they had administered PRN medicines.

Where people received their medicines covertly (disguised in food without their knowledge) records confirmed these had been authorised by the GP and pharmacist, and a mental capacity assessment and best interest decision had been completed. Controlled drugs were managed safely in line with associated legislation.

Staff had received training in safe handling of medicines, and their competency were assessed. We observed a medicine round and saw that medicines were administered in a safe manner, maintaining people’s dignity and respect. The nurse was patient, took their time, ensured the person had safely taken their medicine before leaving, and asked if the person required pain relief.

A recognised pain assessment tool was used to support staff in recognising pain for people who were unable to verbalise their pain or discomfort.

Relatives expressed confidence that medicines were managed safely for their family member. They confirmed any changes to prescribed medications were clearly communicated to them.