We carried out a review of the data available to us about Westhaven Care Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Westhaven Care Home, you can give feedback on this service.
We found the following examples of good practice.
At the time of our inspection the home was recovering from an outbreak of Covid-19. Staff were supporting people to remain safe, however, due to people’s dementia and memory loss it was not always possible to ensure people remained socially distanced. The registered manager and staff had made some changes to seating arrangements in the communal areas to support this.
The home had designated housekeeping staff to maintain appropriate levels of cleanliness. This included regular and deep cleaning of bedrooms, communal areas, bathrooms and toilets. All staff ensured regular disinfection of frequently touched surfaces of the home for example door handles and keypad entry systems. Any new admissions to the home were tested prior to admission and the registered manager followed government guidance.
Current guidance was being followed in relation to infection prevention and control. Personal Protective equipment (PPE) stations were located around the home and staff were wearing PPE appropriately. Visiting was in line with government guidance, people entering the home had their temperatures taken and PPE was provided. The manager had a programme in place to ensure people and staff were tested regularly. This was alongside twice daily temperature testing for everyone and observing people for any signs or symptoms of Covid-19.
We found the following examples of good practice.
The provider and registered manager had implemented appropriate procedures within the service to help minimise the spread of infection and help maintain people’s safety during the COVID-19 pandemic.
Infection prevention and control (IPC) guidance and visiting protocols were shared with people, so everybody was aware of guidance and the procedures in place when visiting. A thermal imaging camera recorded people’s temperatures when entering the building, and highlighted if people were not wearing face masks.
Staff had received IPC training, including the correct use of personal protective equipment (PPE) and we saw this in use. Regular cleaning schedules had been developed and were adhered to by a team of housekeeping staff and care staff. Staff changed into their uniforms when they arrived at the home, to help prevent the spread of infection.
Staff followed shielding and social distancing rules and encouraged people to maintain social distancing where able to. The communal areas, such as lounges, dining rooms and staff break areas, had been adapted to enable social distancing. Risks to people and staff had been assessed and appropriate measures taken to reduce risks. People had their temperature and oxygen saturation levels monitored twice daily so relevant support and treatment could be provided quickly.
Staff and people living in the home underwent regular COVID-19 testing and timely actions were taken if anybody tested positive, to help prevent further spread.
A visiting room had been developed to enable safe, socially distanced visiting with plastic screens and a separate entrance. When people were unable to visit, staff supported people to maintain contact with their family members using telephone calls, iPad’s and portals for video calls. Relatives meetings were also held via zoom to enable relatives to remain updated and engaged.
Safe procedures were in place for admitting people into the service in line with current guidance.
We were assured this service were following safe infection prevention and control measures to keep people safe.
Westhaven care home is a care home providing nursing and personal care for up to 52 people. At the time of the inspection there were 45 people living in the home, some of whom were living with dementia. The home is based over three floors with lift access to all floors.
People’s experience of using this service and what we found
People told us staff were, “Wonderful”, “Kind” and “Like friends.” Staff had developed meaningful relationships and knew the people they supported well, including their individual preferences regarding their care. People’s independence, dignity and privacy were promoted and protected by staff.
People told us they felt safe living in the home. There were sufficient numbers of safely recruited staff available to support people. The environment was safely maintained and risks to people had been assessed and mitigated. When necessary, referrals had been made to the local safeguarding team appropriately.
People’s consent to their care was sought and recorded in line with the principles of the Mental Capacity Act 2005. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People’s needs had been assessed and they were supported to access relevant healthcare services when needed, to meet their needs. People’s specialist dietary needs and preferences were known and met by staff.
Detailed and individualised care plans were in place to inform staff how best to meet people’s diverse needs. A range of activities were available to people, both within the home and in the local community. Staff were aware how best to communicate with people to ensure they were able to engage and have their views heard effectively. A system was in place to manage complaints and people were aware of this. Staff had been trained to provide holistic end of life care and people’s lives were celebrated.
Systems were in place to monitor the quality and safety of the service. When necessary, actions were taken to improve the service. The registered manager was aware of their responsibilities and strived to ensure good quality care was provided to people.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 20 October 2018). We identified breaches of Regulations 12 (Safe care and treatment) and 17 (Good governance) at the last inspection. The provider completed an action plan to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
This was a planned inspection based on the previous rating.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Westhaven is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Westhaven is registered to support up to 52 people. At the time of the inspection, there were 45 people living in the home.
This is the first comprehensive inspection since changes were made to the providers registration, therefore there is no previous rating.
A registered manager was 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. Feedback regarding the management of the service was positive.
We looked at how risk was managed and found that it was not always assessed and managed safely. Personal emergency evacuation plans did not provide sufficient information to ensure people could be safely evacuated in the event of an emergency and staff had not received training in how to use the evacuation equipment.
Medicines were stored safely and protocols were in place for medicine prescribed as and when required. However, sufficient information had not been recorded to ensure medicines administered covertly (hidden in food or drink), were administered safely.
Information regarding applications to deprive people of their liberty was not robustly recorded and it was not always clear whether an application had been made, or an authorisation was in place. However, we found that appropriate applications had been made.
People’s consent was sought regarding their care and treatment. However, mental capacity assessments completed were not always in line with the principles of the Mental Capacity Act 2005. We made a recommendation regarding this in the main body of the report.
Care plans were not always in place to guide staff how to meet all of people’s identified needs. However, the care plans we viewed were detailed and reflected the preferences of the person to enable staff to get to know them as an individual.
People felt safe living in Westhaven and staff were knowledgeable about safeguarding and how to raise concerns.
Records showed that appropriate recruitment checks had been completed to ensure staff were suitable to work with vulnerable people. Some people told us there were not always enough staff on duty, especially at weekends. Since the inspection the registered manager has told us an extra member of staff is now on duty each weekend.
People were supported by staff and external health professionals to maintain their health and wellbeing.
Staff were supported through induction and supervisions, although some staff felt they would benefit from more regular supervisions. Training was provided to help ensure staff had the knowledge and skills to meet people’s needs.
People told us they enjoyed the meals available and that they always had a choice.
Staff were kind, treated people with respect and protected their dignity and privacy. People were encouraged to be as independent as they could be.
People felt able to speak to staff and raise concerns when needed. They were confident they would be listened to. Friends and family could visit at any time and were always made welcome by staff.
People had choice in how they spent their day and were supported and encouraged to make their own decisions. A range of activities were available both within the home and in the local community.
A system was in place to manage complaints appropriately.
Systems in place to monitor the quality and safety of the service were not effective. Audits did not identify all of the concerns we highlighted during the inspection and actions identified through the audits, had not all been addressed.
Systems were in place to gather feedback from people regarding the service.
You can see what action we told the provider to take at the back of the full version of this report.