Westside Nursing 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 Requires Improvement. At this assessment the rating has remained 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 and staffing.

This service scored 47 (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. Lessons were not always learnt to continually identify and embed good practice.

Leaders did not always embed learning and actions following an incident, we reviewed an incident form. This contained details of an incident involving a person and staff. Care plans had not been reviewed in response to this incident and there was no information recorded to show that lessons had been learned.

Staff told us they felt comfortable raising issues with management and they were confident that actions would be taken. A duty of candour policy and an accident and incident policy were in place.

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.

Systems were in place to provide information to healthcare partners in the event of an emergency admission to hospital. Care plans were reviewed if people’s needs changed following discharge from hospital. Care records included information from hospitals to support these reviews.

A care staff member said, “If there is a new resident the night nurse will ask staff if they know about the new person, even if they are tired, they will take that time. The staff can also look at the care plan on their device and speak to any of the nursing staff.”

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 who used services and their relatives did not raise any concerns about their safety.

Staff understood their safeguarding responsibilities. They were able to explain the actions they would take if they suspected abuse. However, not all staff had completed up to date safeguarding training.

Safeguarding records were in place which included referrals to the local authority and notifications to the CQC. Safeguarding policies were in place.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

A DoLS policy was in place and a system was in place to monitor DoLS to ensure applications were made where appropriate. We reviewed the records of a person with an authorised DoLS. Staff were following the conditions set when the DoLS was authorised.

The provider did not work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans were in place but did not always contain sufficient details for staff on how to support people when distressed and the language in the care plans was not always appropriate, for example, a person was described as having ‘problematic’ behaviour and another person’s care plan referred to staff rebuking the person if their behaviour was ‘aggressive’.

Documentation was completed when people showed distress and these events were analysed , however action was not always taken to minimise the risk of reoccurrence. Not all staff had completed training to support people in times of distress.

We were told that staff did not restrain people at the service and did not receive any concerns from people or relatives in relation to this. However, a restraint policy was in place and was not appropriate. This policy was immediately removed and an alternative policy put in place.

The provider’s website contained a statement that, ‘Westside Nursing Home operates a transparency philosophy, therefore for the safety of all the residents, the home operates a locked system for the doors. The home is located on a busy main road. Therefore residents who want to go out are accompanied by a member of staff.’ We raised this with the registered manager as this statement does not consider each person’s individual risks and rights to leave the home unaccompanied by staff where appropriate. The registered agreed to contact the provider to remove this statement from the website.

Risk assessments were in place to support staff to manage risks, however, risk assessments for flammable creams were not in place. These were put in place during the assessment. Staff completed training regarding the management of risks including fire safety and first aid training.

The provider did not 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.

Systems were in place to ensure equipment and the premises were monitored as required, however they were not fully effective.

We identified concerns with the environment which included poorly functioning doors, bedroom and bathroom windows without restricted opening, thickening agents stored unsecured in bedrooms which could cause harm and some equipment that required replacing.

A legionella risk assessment had been completed; however, there was no evidence that the provider had taken all the identified actions to address the risks identified in the assessment.

The registered manager took action to start to address some of these issues during the assessment visit, however, some of these actions could not be immediately completed and we will continue to monitor completion.

People did not know where call bells were in order to call for assistance from staff. A person said, “I would just wait until I see someone.” Another person told us that they would call for help if they needed it.

We observed staff safely using equipment to help people to move. Health and safety policies were in place and staff completed health and safety training and fire training.

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.

People told us that there were not enough staff. People told us that they could not always understand staff, which at times made communication difficult. We observed that communal areas were often unsupervised by staff during our assessment visit.

The service relied on a manager who worked four days a week, with no other management cover in place. This meant there was a risk of reduced oversight when the manager was unavailable. The activities staff member worked only 8 hours per week. We identified a number of issues during the assessment, including limited activities provision, which were linked to staffing levels.

The provider was not using a staffing tool to calculate staffing levels and the call bell monitoring system was not being regularly audited to check how quickly bells were being responded to and assess whether sufficient staff were on duty.

Most staff told us there were sufficient staff. A staff member said, “Staffing levels are good at present, they were struggling in the afternoons as one of the three carers used to have to go into the kitchen to serve tea, they now have a kitchen assistant to do this, so it is much better.” Management told us that an additional care staff member and bank care staff were being recruited.

Training records provided showed a number of staff who had not completed some training courses or had not completed refresher training in line with the provider’s expectations.
Despite this, staff told us that they felt supported and we saw that they received induction, training and appraisal. Most staff were receiving supervision, however, nursing staff were not receiving clinical supervision. This issue had been identified during a visit by a commissioner in October 2025. Nursing staff registration had not been checked to ensure staff remained registered to practice; this was rectified during the assessment.

Staff recruitment processes were followed to ensure all the required checks for when staff worked in care had been completed. This included obtaining references of previous work experiences, checking the reasons for any gaps in employment history, obtaining a Disclosure and Barring Service (DBS) check. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Appropriate information was also kept in relation to agency staff.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Risks of infection were not managed and controlled. Equipment was not always clean. Monitoring systems had not been effective in identifying and addressing the concerns we saw during our inspection.

These concerns included stained bedside protectors, an over-filled external clinical waste container, unclean commode chairs and bathchairs. Linen, mops and buckets were not stored correctly and there were gaps in temperature monitoring for the kitchen fridge and freezer.

Cleaning schedules did not cover all areas of the home. IPC audits were completed by staff but had not identified and addressed the issues identified during the assessment.

The provider took action to address some of these issues during the assessment visit, however, some of these actions could not be immediately completed and we will continue to monitor completion.

An Infection prevention and control (IPC) policy was in place. Staff had completed IPC training.

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

The provider did not make sure that medicines were managed safely. Audits in place had not identified and addressed the issues we found during this assessment. A controlled drugs audit had not identified two controlled drug administrations that had not been countersigned.

We identified a number of medicines management concerns. Creams were stored in bedrooms, but temperatures were not being monitored to ensure that they were being stored in line with recommended temperatures. Two staff had not received medicines competency assessments in the last year and medicines documentation was not always completed in line with safe medicines management guidance. Evidence was provided following the assessment visit to show that medicines competency assessments had been completed following the visit for the staff that had not previously received them.