Date of assessment: 30 May to 19 June 2024. The service had made improvements to the way they protected people from risk and had also improved some areas of governance. At this assessment we identified areas for improvement linked to auditing, which were addressed during the inspection. We judged the previous breaches had been met and the assessment rating has improved from requires improvement to good in safe, effective and well led. This means the overall rating of the service is now good. We saw staff practice valued people’s individuality and the staff group were attentive and spent time chatting with people. There was an emphasis on promoting people’s well-being and providing meaningful occupation, including building a relationship with relatives and visitors.
PDF cached but not yet analysed by Claude; set ANTHROPIC_API_KEY and re-run npm run etl:reports -- --location 1-115717918.
West View, a 28-bed residential care home, was rated Requires Improvement overall following an unannounced inspection in October 2023, with breaches of Regulations 11, 12, and 17 resulting in two warning notices. Key failures included inadequate risk monitoring (weight loss, hydration, diabetes), unsafe medicines storage, absent mental capacity assessments, and governance systems too weak to detect these shortfalls, despite a positive care culture and satisfied residents.
Concerns (10)
criticalCare planning: “people were not always protected from the risk of unsafe care as their care needs and associated risks had not been routinely assessed, updated and monitored.”
criticalMedication management: “room and fridge temperatures where medicines were being stored, were not always recorded daily. In September 2023 temperatures were only checked on 8 days.”
criticalSafeguarding: “Following the inspection we made 4 safeguarding referrals to the local authority about people's care and support.”
criticalGovernance: “Quality assurance and governance systems...had failed to identify when people had lost weight, had not received sufficient to drink or were not having their diabetes monitored effectively.”
criticalConsent / capacity: “mental capacity assessments and best interests decisions had not always taken place. This meant that restrictions may be placed upon people that may not be appropriate.”
moderateMedication management: “Not all medicines prescribed to be administered as and when required (PRN), had guidance in place to inform staff when they would be appropriate to be given.”
moderateIncident learning: “there was no process in place to analyse accidents and incidents on a wider scale therefore identifying potential accident/incident areas within the service.”
moderateStaff training: “there were gaps in the staffs' training. The finance manager told us they had identified that there were gaps in staff training and had produced a training plan.”
moderateSupervision / appraisal: “The management team told us they had identified that the frequency of formal staff supervision and appraisal needed improvement.”
moderateRecord keeping: “audits were not in place to review people's care plans and some records had not been reviewed for a number of months.”
Strengths
· People and relatives spoke positively about the service; people described staff as 'lovely', 'wonderful' and felt safe and well looked after.
· Staffing levels were sufficient and staff were recruited safely with appropriate DBS checks and references.
· Infection prevention and control practices were assured across all assessed areas including PPE use, admissions, and outbreak management.
· The service had good working relationships with healthcare professionals including weekly GP visits and community nurse support.
· A calm, positive culture was observed with person-centred interactions at mealtimes and throughout the service.
Quality-Statement breakdown (17)
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Using medicines safelyRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
effective: Ensuring consent to care and treatment in line with law and guidanceRequires improvement
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawRequires improvement
effective: Supporting people to eat and drink enough to maintain a balanced dietRequires improvement
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Adapting service, design, decoration to meet people's needsGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staffGood