Westley Court Care 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

At our last inspection we rated this key question requires improvement. At this inspection the rating has changed to good. Since our last inspection we found improvements had been made on how risks to people were managed and recorded. Accidents and incidents were reviewed and analysed by the registered manager. People’s dietary requirements were clearly recorded and communicated. Some refurbishment work had been undertaken, these areas were welcoming and homely. However, some parts of the building remained tired and needed attention. Staff did not always demonstrate a good understanding of the Mental Capacity Act and how they applied it in practice.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People we spoke with had not had the need to raise any concerns or issues. However, we spoke with a family member who had, they told us, “They [the provider] listened and addressed concerns. They [the provider] try and rectify problems”.

Staff told us regular team meetings were held where they could put their ideas forward to make improvements. We saw minutes of meetings where information was shared, and discussions held in relation to areas that needed to improve. The registered manager told us they shared learning from events which had occurred in the service.

Processes were in place for staff to record any accidents or incidents. These were reviewed by the registered manager. Actions taken to reduce the risk of further occurrences were documented and discussions held with staff to ensure lessons were learnt. The provider used information gathered from surveys completed by people and their relatives to make improvements to the service. Where complaints had been received these were investigated and outcomes documented, and appropriate actions taken to prevent similar situations occurring.

A relative told us they had been involved in an assessment prior to their family member moving into the service. People told us they regularly saw the doctor or advance nurse practitioner from the local surgery who provided weekly visits to the service. People were also supported to access other health care professionals such as the speech and language therapist and physiotherapist.

The registered manager told us if people needed to go to hospital, they had a hospital passport which contained important information including a summary of the persons care needs.

We contacted the Local Authority as part of our assessment who confirmed the findings from their monitoring visits had been positive overall.

People’s needs were assessed before moving into the service to ensure their needs could be met. Where appropriate people’s relatives were involved to provide important information. People’s needs were regularly reviewed. The provider worked closely with partner agencies to ensure people were receiving appropriate support and were reviewed by the relevant healthcare professional when their health care needs changed.

People we were able to speak with told us they felt safe living at Westley Court Care Home. One person said, “I feel safe here, someone is always around”. Another person told us, ”As long as I have the buzzer, I am not worried. When I press it, they [staff] come very quickly. I wouldn’t want to be anywhere else”.

Staff told us they had completed safeguarding training and understood their responsibility to report concerns. We asked staff about their knowledge of the Mental Capacity Act and Deprivation of Liberty safeguards (DoLS). Some staff lacked knowledge around this and were not aware which people had an DoLS in place. This meant people may not always be appropriately supported.

During our assessment we found a range of risks were identified and assessed to keep people safe. However, we found bedroom doors did not have locks to protect people from unwanted entry or protection of their personal belongings. These were potential risks that had not been identified by the provider and needed further assessment due to the nature of some health conditions of the people living at Wesley Court Care Home. These conditions included dementia related illnesses and associated cognitive impairment. We discussed our findings with the registered manager. On the second day of our visit the registered manager informed us they had asked people individually if they would like to be able to lock their door, none did at that time. Some assurances were given that if anyone did prefer to be able to lock their door arrangements would be made to accommodate this. ‘Speak up’ posters were displayed around the service; this guided staff on how to raise concerns. We observed people were treated with dignity and respect and there was a warm and friendly atmosphere in the service.

Staff received training in safeguarding and the provider had safeguarding and whistleblowing policies in place for staff to refer to. The registered manager made referrals to the local authority and submitted notifications to the Care Quality Commission (CQC) in relation to safeguarding concerns. The provider had policies and procedures in relation to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Staff completed mental capacity assessments and submitted applications to the Local authority.

Some people we spoke with told us they were not involved in reviewing their care records. One person told us, “ I presume there is a care plan, I don’t know”. Another person said, “I am concerned why I am taking so many tablets, but I have never had the chance to discuss why I am taking these”. However, one relative told us they had been involved in discussions about their family member having a sensor mat in their room as they were a high risk of falls. People told us they were well cared for, and staff responded quickly to their needs. One person told us how 2 staff supported them to make sure they were safe.

Staff understood people’s risks and what they needed to do to keep people safe when supporting them. Information about new people moving into the service was shared with staff prior to their admission.

Some improvements had been made from our last inspection on how risks to people were recorded and managed. Where people required support with repositioning to prevent skin damage, supplementary records showed this was undertaken at regular intervals as stated in people’s care plans. However, we did find that where people required special mattresses, daily checks were not carried out effectively. We checked 3 people’s mattress settings and found they were incorrect despite checks being carried out during the night. This increased the risk of skin damage.

Monthly clinical review meetings were held with the manager and clinical staff to review people and any changes. Electronic care plans and risk assessments outlined people’s identified risks and flagged up when these were due to be reviewed. Most people’s records had been reviewed by the target date and detailed the equipment needed to help maintain people’s safety and the frequency of care interventions.

People and their relatives raised no concerns about the environment.

The service had been without a maintenance manager for several months and support was being provided 1 day a week from another of the provider's services. The new maintenance manager started their induction on the second day of our assessment. Staff told us they would record in the maintenance book any repairs or problems they identified; however, the registered manager told us the maintenance book was no longer being used and a new system had been introduced to record safety checks, audits and report any repairs needed. This increased the risk of repairs being missed if staff were recording in the wrong place.

We observed equipment in the home was not always in a good state of repair. For example, a shower chair was rusty, this meant staff were unable to clean it effectively. Some equipment required cleaning or replacing. Broken furniture and equipment were found stored in an unlocked communal bathroom. This increased the risk of people tripping and falling.

The provider had systems to monitor the safety of the environment which were effective at making improvements in some areas. For example, monthly bedroom checks were completed to ensure water temperatures were safe and bedrails were fitted correctly and in good condition. However, some of the concerns referred to in this report had not been identified or actioned by the provider. Where safety concerns had been identified from internal and external checks, it was not clear if actions had been taken as these had not always been recorded. People had personal emergency evacuation plans in place. Fire tests and drills were carried out to ensure staff were trained in how to evacuate people safely in the event of a fire. Where people were at risk of falls, care plans and risk assessments had been completed and identified measures needed to keep people safe. We saw some people had equipment in place to reduce the risk of falls.

We received positive feedback from people and relatives about staffing levels. Comments included, “I think there are plenty of staff. Day or night, even at 2am they [staff] will make me a cup of tea if I want it” and “I think there are enough staff. They are friendly and experienced”. Another person told us, “I think its lovely here. The staff are so thoughtful, and they provide good care”.

Staff we spoke with felt the team worked well together and supported each other. One staff member said, “Some days are busier than others, but we help each other out”. Staff received training that was relevant and supported them in their role. The registered manager told us they had some vacancies which they were actively recruiting to. Agency staff were used to backfill some of the vacancies. The manager used the same agency workers where possible to ensure a degree of consistency.

On the first day of our visit the registered manager was on annual leave, the deputy manager told us they had a minimum of 1 nurse and 5 care assistants on shift during the day. We saw there were delays in responding to call bells despite the correct numbers of staff being on duty. On the second day of our visit, we found call bells were responded to promptly. The registered manager told us they regularly reviewed the call bell response times and addressed any concerns at the daily meetings. We observed staff meetings were held regularly. Discussions were held about what was working well and where changes were needed to make improvements. Staff were able to contribute and offer suggestions. We reviewed the training matrix, and this confirmed staff training was mostly up to date.

Staff were recruited safely. Pre-employment checks were carried out prior to new staff commencing employment including Disclosure and Barring Service (DBS) checks. DBS checks provide information including details of convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. The provider used a staffing level dependency tool to calculate staffing requirements for the service. Quarterly staff meetings were held in line with the providers policy. However, not all staff had received regular one to one meetings with their manager to discuss their performance and development.

People and their relatives did not raise any concerns about the cleanliness of the service. One person told us, “I would say that this home rates a lot higher than other homes, one thing I like about it, it’s clean”.

The housekeeping team followed the providers cleaning schedules. The registered manager had oversight of these and told us they reviewed the schedules and completed spot checks, any areas of concern were highlighted and signed off once addressed.

We found some concerns regarding the cleanliness of the service, for example the kitchenette had marks and stains in the sink, cupboards and fridge. Following feedback, the registered manager took action to address, we found improvements had been made when we returned. There were some areas of the service which were damaged and needed repair. This meant that cleaning could not be carried out effectively and this increased the risk of infection.

The provider had an up-to-date infection, prevention and control policy. Cleaning schedules were in place for the housekeeping team to follow which the registered manager checked and investigated any gaps in these before signing them off. However, the providers processes to monitor the cleanliness did not identify some of the areas we found during our assessment. Staff had received infection control and food safety and hygiene training. Personal protective equipment (PPE) was worn where required.

One person told us, “I get my medicines on time and have never missed any”. People who wanted to continue to administer their medicines to maintain their independence, were supported to do so where appropriate.

Staff told us they had received medication training, and their competencies regularly assessed. The registered manager informed us the in-house trainer was preparing to deliver training for buccal midazolam (an emergency medicine to use in the event of a seizure). The training would enable staff, to provide this support which at the time of our assessment was being provided by external health care professionals.

Weekly and monthly medication audits were undertaken by the registered manager. Actions identified from the audit were recorded and actioned. For example, it had been noted the medication room had exceeded the required temperature, the registered manager recorded they had escalated this to head office. However, we found audits had not identified that instructions for one person’s medicines were not clear. We discussed this with the registered manager who promptly sought advice from the doctor and clearer instructions were issued. An electronic medication record system was in use, this alerted staff when medicines were due. Staff were trained in medicines administration and their competencies assessed. Records contained a photograph of the person, any allergies and the way they preferred their medicines to be given. Staff completed regular stock checks of medicines, storage temperatures were monitored, and medicines were disposed of safely.