Westhorpe Hall

Westhorpe Hall is a residential care home providing personal care to nine people at the time of our inspection. The service supports older people including people living with dementia. The service can support up to 21 people, but the first floor of the service had been taken out of use by the provider. The service is in a listed building with enclosed gardens and is located in a rural area.

People’s experience of using this service and what we found

The arrangements in place to keep people safe were more robust and risk management systems had been strengthened since our last inspection. Recording of safety checks had improved but there were some omissions in the recording of welfare checks.

The service continues to experience challenges recruiting staff and was dependent on agency staff. This was compounded by issues around staff deployment and a lack of activities. We were assured by the provider that they had a plan in place to address our findings.

Incidents and accidents were logged and reviewed to identify learning. Agency staff received an induction into working at the service.

Medicines practice had been strengthened since our last inspection. Medicines were securely stored and competency assessments for staff were in place.

Safeguarding concerns were managed in a transparent way and although we identified one omission, we were assured that overall practice had improved since our last inspection.

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.

There were systems in place to manage infection control and personal protective equipment (PPE) was appropriately stored and practice audited. The laundry was however disorganised making it difficult to separate clean and soiled linen, the provider told us that they had plans to refurbish this area.

The service has not had a stable leadership team for some time. The providers new management team had started to provide some stability and staff morale was improving. People and their relatives expressed confidence in the changes that had taken place and spoke highly of staff.

Audits on quality and safety had been completed but further work is needed to embed changes at the service.

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 inadequate (18 March 2022). The provider completed an action plan after the last inspection 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.

This service has been in Special Measures since (18 March 2022). During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We undertook this inspection to check whether the Warning Notice we previously served in relation to Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met.

This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Westhorpe Hall on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Westhorpe Hall is a residential care home providing personal care to eight people at the time of our inspection. Some of those people were living with dementia. The service can support up to 21 people. The service is in a listed building with enclosed gardens. It is located in a rural area and people would require support to access the local community.

People’s experience of using this service and what we found

Risks were not always assessed or effectively managed to keep people safe. Staff were not provided with clear guidance on how risks such as those associated with people’s health should be managed.

Documentation was not always fully completed, and we could not be assured that people were receiving care and support in line with best practice.

Incidents were not always identified, escalated or collated to ensure provider oversight and learning to reduce the risks to people.

Safety checks were not robust to ensure the safety of the premises. We found gaps in the provider oversight of fire safety and legionella.

The service had experienced a high turnover of staff and challenges recruiting staff. As a result, there was a significant use of agency staff. This had been compounded by a recent COVID 19 outbreak and the contingency plans in place for ensuring there were enough staff on duty were not robust.

There were processes in place to check on the suitability of staff prior to them starting work at the service. However, the checks and induction provided to agency staff needed improvement.

Medicines were not always managed in line with professional guidance. Competency assessments for staff were not always in place and topical medicines were not stored securely which placed people at risk of harm.

Safeguarding concerns were not always escalated, and staff were not clear about the actions they should take, where there was a concern.

There were systems in place to manage infection control, but the home’s policy had not been updated since the start of the pandemic. Improvements were needed in areas such as the storage of personal protective equipment (PPE) and auditing. We have signposted the provider to resources to develop their approach.

The provider was following the government’s guidance on whole home testing for people and staff. This included rapid testing and weekly testing. Visits by relatives had been facilitated by the service.

The service was not managed effectively and had not had a stable leadership team for some time. Staff morale was low. A new manager started work at the service during the inspection. Audits on quality and safety had not been consistently completed and those in place had not identified the shortfalls we found in areas such as medicines, care planning and safety.

Rating at last inspection

The last rating for this service was Good (published 8 July 2021).

Why we inspected

This inspection was prompted by a review of the information we held about this service. We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

We received concerns in relation to medicines and the delivery of care. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Good to Inadequate. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report. For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

The overall rating for this service is ‘Inadequate’ and the service is in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Westhorpe Hall is a residential care home providing personal to nine people at the time of our inspection. Some of those people were living with dementia. The service can support up to 21 people.

The service is in a listed building with enclosed gardens. It is located in a rural area and people would require support to access the local community.

People’s experience of using this service and what we found

Staff used personal protective equipment, such as gloves and aprons to prevent the spread of infection. The service had undergone changes to the environment to improve the infection prevention control procedures.

Staff assessed and reduced people’s risks as much as possible. There were enough staff to support people with their care and support needs. The provider carried out key recruitment checks on potential new staff before they started work to ensure they were suitable.

People received their medicines and staff knew how these should be given. Checks were in place to ensure that medicines were given safely and stored correctly.

The service was recruiting both a registered manager and a deputy manager. The previous registered manager had not been in the service for very long. The changes in the management structure over the last 12 months had been disruptive to the service and to the morale of staff. The current interim management structure in place had been well received by relatives and most staff, however, was only a short-term arrangement whilst both positions were being recruited to. The service required a period of stability and ongoing support from the provider to embed the improvements which had been made and to support the staff team.

The provider had introduced new ways that people, staff and relatives could give feedback and suggestions anonymously. People were asked their views of the service and action was taken to change any areas that they were not happy with. Concerns were followed up to make sure action was taken to rectify the issues raised

The interim manager and nominated individual had worked closely with stakeholders, including the local authority, safeguarding team and infection control team to improve practice within the service.

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 17 November 2020) which was a focused inspection. There was one breach of regulation. The provider completed an action plan to show what they would do and by when to improve.

We carried out a targeted inspection (published 7 April 2021) to check compliance with the breach of regulation. We found the provider had made the necessary improvement in that area, but we identified another breach of regulation. We did not rate the service on this occasion. The provider completed a further 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

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions safe and well-led which contain those requirements.

The ratings from the last comprehensive inspection, published 01 October 2019, for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Westhorpe Hall on our website at www.cqc.org.uk.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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.

Westhorpe Hall is a residential care home providing personal care to up to 21 older people in one adapted building. On the first day of our inspection there were 13 people using the service, some living with dementia.

People’s experience of using this service and what we found

On the first day of our inspection on 17 February 2021, we undertook an inspection to check if the provider’s systems relating to infection control were effective. This was following concerns raised by other professionals. We identified areas for improvement and told the management team what we had found. The provider was responsive to our suggestions for improvement and took swift action to address the shortfalls identified. The provider updated us following the first visit on the improvements made and planned. The improvements were ongoing, and all were not yet fully implemented and embedded in practice. Despite the improvements made, we were concerned the provider had not independently identified the shortfalls and taken action, we have identified a breach of regulation relating to infection control.

Other professionals provided feedback to us (Care Quality Commission) and the provider regarding their concerns, such as staffing levels in the service. We inspected the service again on 4 March 2021, to check the staffing levels and if people were receiving safe care.

We found the provider had taken action to improve the shortfalls we, and other professionals had identified. Increased monitoring and support from senior management was in place to assist the service to independently identify shortfalls and introduce systems to improve.

We found the provider had increased the staffing levels. The registered manager and provider were monitoring and assessing the numbers of staff required and the ways in which staff were deployed to ensure they could keep people safe and meet their needs.

At our last inspection, published November 2020, we had found a breach in regulation relating to medicines management. We also checked improvements had been made in this area. Systems had been reviewed and updated in relation to the safe management of medicines. This assisted the management team to identify risks and take action to reduce them.

There were systems in place to assess the risks to people in their daily living and guidance provided to staff in how to reduce these risks. One person told us they felt safe and said, "I am safer here than anywhere else."

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 17 November 2020) and there was a breach of regulation relating to the safe management of medicines. The provider completed an action plan after the last inspection 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 regulation relating to medicines. However, a further breach was identified relating to infection control.

Why we inspected

The targeted inspection was prompted in part due to concerns received about medicines, infection control, staffing and safe care. A decision was made for us to inspect and examine those risks. The overall rating for the service has not changed following this targeted inspection and remains requires improvement.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We found several improvements had been made by the second visit of our inspection. These improvements had recently been made and were not yet fully implemented and embedded in practice. Please see the safe sections of this full report.

You can read the report from our last inspections, by selecting the ‘all reports’ link for Westhorpe Hall on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We have identified a breach of regulation in relation to infection control at this inspection.

You can see what action we have asked the provider to take at the end of this full report.

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.

The service is a listed building with enclosed gardens. It is located in a rural area and people would require support to access the local community.

People’s experience of using this service and what we found

Peoples medicines were not always managed safely, which increased the risk to people.

Staff had not always completed risk assessments and care plans to give guidance on how to monitor people's assessed risks. However, the manager assured us that these were being updated, and sent us updated documents within our requested timeframe.

Relatives of people who lived at the service were satisfied that people were safe and well cared for. They told us that communication was good, and they felt listened to and involved in their family members care.

There were enough staff to meet people's care and support needs. Recruitment procedures were in place to check that new staff members were suitable to work at the service.

Staff involved and worked with external professionals to help people maintain their health and well-being. The manager and senior staff made sure appropriate people and organisations such as the local authority safeguarding team, were informed when things went wrong.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Requires Improvement (30 September 2019).

Why we inspected

We received concerns in relation to staffing and the impact this had on people living in the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service remained the same. This is based on the findings at this inspection.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Westhorpe Hall on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to the safe management of medicines at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Westhorpe Hall is a residential care home providing personal care for up to 21 older people and some of those people are living with dementia. At the time of our inspection 18 people were living at the service.

The service is a listed building with enclosed gardens. It is located in a rural area and people would require support to access the local community.

People’s experience of using this service and what we found

At the start of our inspection, the registered manager was covering a designated care shift due to staff sickness. No other staff were available to cover and although attempts had been made no agency staff were available to support at short notice.

The dependency scores to determine the number of staff required to be on duty to meet people’s individual needs had not been completed for the previous two months. Although both the registered manager and deputy enjoyed supporting people directly and used this opportunity to demonstrate leadership and work alongside the staff. This was at the expense of management duties such as maintaining the dependency scores. The operational manager informed us at the inspection they were reviewing the staffing arrangements with the registered manager.

The service quality assurance processes were not fully effective as the auditing in place had not identified that the dependency tool to determine people’s needs was not being reviewed and updated on a monthly basis. People’s care plans were being reviewed and rewritten in the corporate style of the organisation but not all had been completed. Due to focusing upon providing personal care the registered manager had not had the time to dedicate to writing the care plans with the people living at the service.

Risk assessments had been carried out and recorded to advise staff upon how to keep people safe. People’s medicines were managed safely and all necessary staff pre-employment checks had been completed. Although there was a vacancy in the cleaning staff, the service was clean.

New staff received appropriate induction training and established staff were provided with regular training updates to ensure they had the required knowledge and skills necessary to meet people’s needs. The service was well maintained and people were supported to participate in the planning and preparation of meals as they wished.

People were supported to have 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.

Staff were caring and responded promptly to people’s needs. People’s care plans were being reviewed and changed to a new recording system in line with the new services policies and procedures. Complaints received had been appropriately investigated.

The service had experienced significant management changes since our last inspection and a new registered manager had been appointed.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good. (Report published 17 November 2017). The key questions were all rated good other than Well-led which was rated as requires improvement.

Why we inspected

The inspection was prompted in part due to concerns received which were anonymous regarding staffing levels, insufficient staff training, insufficient food being available and the maintenance of the service.

We have found evidence that the provider needs to make improvements. Please see the; Safe, and Well-led sections of this full report for further details.

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.

The service had 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.

At our last inspection of 8 September 2015 we rated the service as ‘Good’. At this inspection we have rated the service as ‘Good’ overall but Well-led ‘Requires improvement’.

There was an induction procedure and on-going training in place for the staff, as well as planned supervision and appraisals. The induction training of new staff required further organisation and auditing by the registered manager to ensure all training was covered in sufficient detail.

Regular prescribed medicines were recorded accurately but prescribed creams had not been recorded on people’s body maps and there were no individual protocols in place for as required medicines.

Risks to people’s health and well-being had been assessed and recorded with actions to reduce the risk in people’s risk assessments and care plans.

Regular checks of equipment in use at the service were organised to ensure they were fit for purpose.

There were processes in place for the safe recruitment of staff and there were enough staff to provide the care to meet people’s needs. There were systems in place for the safe handling of medicines but there was a need of further recording and auditing of people’s medicine records in particular where creams have been prescribed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People were supported to eat and drink sufficient amounts and were encouraged with regard to their capacity to make choices about food and drink and provide feedback. People received effective healthcare support from a range of external healthcare professionals.

The staff knew people well and there was a person centred culture focussed upon supporting people to meet their assessed needs. Some people living at the service had a diagnosis of dementia and staff had been given additional training in dementia awareness. People's rights to privacy and dignity were valued and respected.

People had been involved in the writing of their care plan. Each person had a care plan written from an assessment of their needs.

Relatives were encouraged to provide feedback on the service and felt they could raise concerns. Complaints were taken seriously, investigated and responded to with understanding.

There was a quality assurance process in operation which required further development by the registered manager to be effective to identify and take actions with regard to the medicines and training issues identified. The registered manager planned to increase and develop with the director the senior staffing at the service to support them. The director visited the service regularly and was well known by the people and staff at the service.

We looked at the care records for five of the 17 people who used the service at the time of our inspection. In addition, we reviewed audit records, incident records, nutrition records and safeguarding records. We considered our inspection findings to answer five key questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? and is the service well led?

Below is a summary of what we found during our inspection;

Is the service safe?

We found that each person had care plans which set out instructions for staff on how to meet people's needs. This meant we could be assured people were protected from unsafe or inappropriate care.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that the service assessed people appropriately which meant we were assured that people's rights were protected.

The service had in place appropriate safeguarding and whistleblowing policies. Staff we spoke with were able to describe the process they would take if they had a concern about someone who used the service. People we spoke with felt safe, one person told us: "I feel safe here. I didn't feel safe at home." The relative of another person told us: "I'm happy that they're safe here, I don't have to worry."

Is the service effective?

Audits carried out by the service were effective and identified any issues with service provision. We were shown evidence to support that issues identified in a recent audit had been completed. This meant we could be assured that the quality assurance processes in place at the service were effective.

People had been given the opportunity to take part in a survey of their views in February 2014. The provider had collated responses from these surveys and written to people who used the service to tell them what action they intended to take in response to the survey. We were shown evidence of improvements and adjustments which had been made to the service following the survey. This meant that we could be assured that people's comments and views were dealt with effectively.

Is the service caring?

We found that each of the five care records we reviewed contained detailed personal information about people, which included their likes and dislikes, hobbies and past history. We observed staff respecting people's individual preferences and wishes.

Care records we reviewed showed that people's care was planned and delivered in a way which promoted people's dignity and ensured their safety and welfare. These records had been reviewed and updated as needed. People had been involved in their care planning and reviews. One person we spoke with told us: "They look after us all right. The care is first class."

We observed that staff interacted with people in a caring way, spending time with people and supporting them to carry out activities or hobbies they enjoyed. One person we spoke with told us "They're so caring, and they always have time for you."

Is the service responsive?

Records showed that people who used the service were supported and received input from health professionals in a timely manner.

Is the service well-led?

The leadership of the service demonstrated that they had taken the necessary steps to ensure the service met the needs of the people it provided care for. The provider has shown they were capable of implementing improvements and change at the service. In doing so they had improved care for people who used the service. This meant we were assured that the service was well led.

Two people told us that they liked living at Westhorpe Hall because " It's a friendly place and very homely.' Another person said "Your clothes are well looked after.' We observed that the people residents looked well dressed with properly matching clothing.

There were many positive comments about the staff one person said that "They are very friendly and there's no favouritism here." Another person said, "The staff will sometimes take us shopping in Stowmarket.'

The provider and manager informed us they wished to implement plans and improve the service for the people using the service and staff and have begun with refurbishing the kitchen. During our inspection the atmosphere in the dining room was calm and peaceful and people were not rushed.

A relative said that they had chosen Westhorpe Hall, 'Because it was like a large family home friendly and homely in a physical environment which did not feel institutional.' A relative informed us "Things have improved enormously since the new Director came in October 2012 and staffing levels have improved as well."

We reviewed care records. We found that improvements had been made in the way that information and risks were recorded in people's care plans. However we still had concerns that some staff were not confident in assessing the risks faced by people using the service and we noted that errors continued to occur.

Whilst some training had taken place, we were concerned that staff have still not been trained in delivering quality care to people with dementia. We saw evidence of supervision for most staff members but we noted that one member of staff had not been formally supervised and so there was no record of their learning and development needs. Given that some staff continued to make errors in risk assessments, there was a continued risk to people's health and wellbeing.