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Archived: Whitbourne House Requires improvement

This service was previously managed by a different provider - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 18 December 2015

We inspected Whitbourne House on the 27 and 29 October 2015 and the inspection was unannounced. Whitbourne House provides care for up to 41 older people, all of whom are living with dementia. On the day of our inspection 39 people were living at the service and one person on a respite (temporary) stay.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Risks in relation to people’s needs were not always recorded accurately and staff we spoke with gave conflicting information to what had been recorded. Medicines were stored and administered safely but protocols for ‘as required’ (PRN) medication, were not in place.

People were protected from the risk of harm and abuse by staff that understood their responsibilities in relation to safeguarding and systems and procedures that were used effectively. People were protected by effective infection control procedures and the environment was clean.

People received a choice of good quality food which they enjoyed. However we found that the nutritional risks were not always assessed accurately.

People were supported by staff that felt confident in their roles and felt supported. The registered manager and staff were aware of their responsibilities under the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The MCA is the legal framework that protects people’s right to make their own choices. DoLS are in place to ensure that people liberty is not unlawfully restricted and where it is, that it is the least restrictive practise.

People were supported by caring staff who respected their privacy and dignity and promoted their independence. Staff were described as caring by the people we spoke with and we also observed a number of caring interactions.

The staff were aware about the people’s needs but records were not always updated clearly to reflect care needs and the level of assistance required to meet these needs. We found that peoples experience of activities had changed and many felt it could be improved.

There were a number of monitoring systems and processes to ensure that the service delivery was monitored. We found that some of the issues we found around the care documentation had not been identified prior to our inspection.

People spoke positively about the management. The manager was aware about the improvements required to the service. The manager and staff told us they wanted to provide good quality care for people. The registered manager explained she was looking at improving the environment to help promote the principles of dementia care. For example, better use of colour contrast.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. You can see what action we told the provider to take at the end of the full version of the report.

Inspection areas


Requires improvement

Updated 18 December 2015

The service was not always safe.

Risk assessments and care plans did not always accurately detail risks to people and provide guidance with how to manage them.

Medicines were stored and administered safely, however we found that the protocols for ‘as required’ medication were not documented appropriately.

People told us they felt safe and comfortable in the service and staff we spoke with demonstrated an awareness of how to report abuse.



Updated 18 December 2015

The service was effective.

People were supported by staff who felt supported and had received effective supervision.

People liked the meals provided and were supported to eat and drink if required in line with documented guidance.

People were supported by a culture that understood the principles of Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

People had access to healthcare support which met their needs.



Updated 18 December 2015

The service was caring.

People told us staff were caring and we observed that staff were compassionate and caring in their approach to people.

Staff communicated clearly with those they supported and were mindful of

their needs.

People’s confidentiality, privacy, independence and dignity were respected.


Requires improvement

Updated 18 December 2015

The service was not always responsive.

People’s care plans were not always personalised and did not provide guidance and detailed direction to staff about people’s care needs.

It was not always possible to evidence that people received the care and treatment detailed in their care plan.

Some people told us that the activities programme could have been improved.

People’s concerns were dealt with proactively and complaints were responded to in a timely manner.


Requires improvement

Updated 18 December 2015

The service was not always well led.

The provider had systems in place to monitor quality of the service, however we found that the issues around documentation had not been identified.

Staff were clear about their roles and responsibilities.

The manager acted on feedback received from people who use the service and their relatives.

Action plans were in place which ensured that the progress required to improve to the service was monitored.