This inspection took place on 16 and 17 August 2018 and was unannounced. Westcombe Park Care Home, is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Westcombe Park Care Home accommodates 51 people in one adapted building. There were 44 people using the service at the time of our inspection.

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.

We inspected Westcombe Park Care Home on 28 and 29 June 2017 and found significant shortfalls. We found multiple breaches of the fundamental standards and regulations. The service was rated requires improvement. Risks to people were not always identified and guidance regarding how to reduce risks was not always followed by staff. We found people’s care and treatment was not always appropriate to their needs or preferences. Systems to monitor risk and the safety and welfare of service users were not always effectively operated and feedback from relevant persons about the running of the regulated activity was not always acted on.

We took enforcement action and served a warning notice on the registered provider.

Following this inspection, we inspected the service on 14 November 2017 and found that the service had acted to comply with the warning notice. Regular checks were being conducted to test fire equipment to ensure they were in working order. The home had a fire risk assessment in place and any actions needed to be taken had been actioned. However, we found a continuing breach of legal requirements because people using the service were not being repositioned in accordance with their needs, which placed them at risk of experiencing discomfort and developing pressure sores. We recommended the home review its staffing levels to ensure people's needs were met appropriately. Following that inspection, the provider sent us an action plan showing how they planned to make improvements.

At this inspection, we found that the provider had made improvements. Staff completed risk assessments for every person and there was detailed guidance available regarding how to reduce risks, which staff followed. Although we received a mixed response from people, we found there were enough staff on duty to help support people safely in a timely manner.

Although the provider had made improvements, we found four breaches of the fundamental standards and regulations. Some aspects in people’s care plans were incomplete and out of date. Medicines were not always managed safely. Staff asked for people’s consent, where they had the capacity to consent to their care. However, staff showed a lack of understanding of the Mental Capacity Act (MCA) and the best interest decision making process. The provider had systems and processes to assess and monitor the quality of the care people received. However, some aspects of quality assurance process required further improvements.

Staff knew how to keep people safe. The service had clear procedures to support staff to recognise and respond to abuse. The registered manager and staff completed safeguarding training.

The service had a system in place to manage accidents and incidents, and to prevent them happening again. The service carried out comprehensive background checks of staff before they started working.

The provider planned to deal with emergencies and staff were aware of the provider’s infection control procedures and they maintained the premises safely.

The provider trained staff to support people and meet their needs. The provider sup

We carried out an unannounced inspection of this service on 28 and 29 June 2017 and found breaches of legal requirements because the systems in place for monitoring quality and safety were not effective in relation to fire risk, risk assessments and care and treatment not always appropriate to people’s needs or preferences. We took enforcement action and served a warning notice on the registered provider in respect of these breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. An action plan was received from the registered manager to show what actions would be taken to meet this regulation.

We received concerns about staffing levels in the home and during this inspection wanted to check staffing levels were adequate to ensure people’s needs were being met.

We undertook this focused inspection, on 14 November 2017, to check that the provider had taken action to meet our legal requirements. This report only covers our findings in relation to the key questions safe and well led and breaches identified in the warning notice. We will follow up on the other breaches of legal requirements in relation to risk and care and treatment in relation to people’s needs and preferences at a later date. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for 'Westcombe Park Care Home' on our website at www.cqc.org.uk.

Westcombe Park Care Home offers residential and nursing care for up to 51 people and is located in the Royal Borough of Greenwich. During this inspection, there were 44 people using the service.

There was registered manager in place. 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 this inspection, we found that the service had taken action to comply with the warning notice. Regular checks were being conducted to test fire equipment to ensure they were in working order. The home had a fire risk assessment in place and any actions needed to be taken had been actioned. Staff had undertaken fire safety training and usage of fire equipment. Staff spoke positively about the training received.

During the inspection, we observed the atmosphere was calm in the home and staff were not rushed when responding to people’s needs. However we observed occasions where people were left unattended in the lounge areas. Feedback from people using the service and care workers also indicated that at times, there may not be enough staff in the home. The registered manager told us there were enough staff and that he would ensure they were deployed appropriately on each floor. The registered manager also told us they were in the process of recruiting additional staff to work in the home.

There were arrangements in place to manage people’s medicines. However we found prescribed topical creams were not stored securely and records were not completed fully to ensure people received topical medicines as prescribed. The registered manager told us this would be addressed straight away.

Records showed that people who were mainly bed bound were not being repositioned in accordance to their needs which placed them at risk of developing pressures sores and experiencing discomfort. Records showed this issue had been highlighted in a quality assurance audit conducted by the service but actions to address this was not yet being fully implemented.

Systems were in place to monitor the service. Checks and audits were carried out by the registered manager and provider. Records showed any action that needed to be taken to make improvements to the service were noted and actioned. However the checks and audits did not identify the issues in relation to repositioning people and the application

This unannounced inspection took place on 28 and 29 June 2017. At our last comprehensive inspection in April 2016 we had found concerns around aspects of monitoring the quality of the service as staff training and recruitment records were not effectively managed. We carried out a focused inspection in October 2016 and found improvements had been made to these areas but further improvements were needed to ensure nurses’ competencies were effectively recorded.

At this inspection there was no registered manager in place. The previous manager was still registered at the service at the time of the inspection, but, no longer worked as manager of the home. A relief manager, who had previously managed the home, and, was therefore familiar with it, had been brought in to manage the home and register as manager until a new permanent manager was recruited. We had been notified about these changes as required. The relief manager was aware of their responsibilities as registered manager. 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 this inspection on 28 and 29 June 2017, we found a breach of regulation as systems to monitor risk were not effective in ensuring recommendations from fire risk assessments were implemented in a timely way to ensure all staff had received relevant fire safety training.

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

We found two other breaches of regulations as staff did not always follow the guidance in people’s care plans about how to monitor and support people effectively to reduce risk. People’s preferences and needs were not always identified or care provided in line with their care plan. People told us and we observed that their need for stimulation and social interaction were not always met.

The relief manager and regional manager took immediate action to address the issues we identified in relation to some specific risks and sent through an activities action plan following the inspection.

There were some good aspects about the way the home was run. People told us that they felt safe and well looked after, that staff were kind and caring and their dignity was respected. They told us staff knew them well and that they were responsive to their needs. Most risks to people were identified and assessed and staff were given guidance about how to reduce risks. Staff spoke with a sense of shared responsibility and enjoyment of their work and we observed some warm interactions between staff and people living at the home. People’s nutritional needs were met and they had regular access to health professionals. Night staff were involved in planned meetings to ensure they felt part of the team and were knowledgeable about people’s needs.

People had an assessed plan of care which they and their relatives told us they were consulted about and this plan was reviewed regularly to ensure it was accurate. There was an effective complaints process in place for people to use.

People’s views were sought about the running of the home and they told us the relief manager was very approachable and listened and acted on any issues. Staff also told us they felt well supported by the management team. There were a series of meetings to monitor the quality and safety of the service and audits were used to track quality and identified learning; some of these auditing systems worked well.

Medicines were safely managed.There were enough staff to meet people’s needs. Staff recruitment was managed effectively.

There were some areas for further improvement. Although staff worked within the principles of the Mental Capac

We carried out an unannounced comprehensive inspection of this service on 20 and 21 April 2016 in line with our special measures policy, to check what progress had been made in respect of addressing serious breaches of regulations identified at a previous comprehensive inspection of 11 and 12 November 2015.

At the inspection on 20 and 21 April 2016 we found the more serious breaches of regulations had been addressed. However, a breach of legal requirements was found as systems to monitor the quality and safety of the service in relation to staff training and recruitment were not always effective. Following the inspection we mutually agreed some conditions on the provider’s registration to help sustain the progress made.

After the comprehensive inspection on 20 and 21 April 2016, the provider sent us an action plan to say what they would do to meet legal requirements in relation to this breach. They told us they would complete the action required by 30 June 2016. We undertook this unannounced focused inspection on the 24 October 2016 to check that they had followed their plan and to confirm that they now met legal requirements.

This report only covers our findings in relation to the focused inspection for one part of the key question is the service well-led? You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Westcombe Park’ on our website at www.cqc.org.uk.

Westcombe Park provides care and accommodation for up to 51 older people living with dementia who may have nursing, care and support needs. At the time of this inspection there were 29 people using the service. There was no registered manager in place. 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. The home had been managed by a relief manager but a new manager had recently been appointed with a view to applying to be the registered manager. They had previous experience of being a registered manager.

At this inspection we found that the provider had made improvements to the systems to monitor staff training and recruitment. Staff records had been audited and staff recruitment records that had been missing at the previous inspection had been located or replaced. Staff training records were now being kept and there was a system to monitor and ensure staff training was refreshed when needed. However records to evidence assessed nurses’ competencies were not always consistently maintained either at the home or by the provider and these required some improvement.

The improvements found were relatively recent and we were not able to judge their consistency or the reliability at this inspection. Additionally, the management of the home was undergoing a further period of change. A new manager had only recently been appointed and was becoming familiarised with the home with the support of the previous relief manager and the recovery team. The previous deputy manager had recently left the service and we were told a new deputy manager was in the process of being recruited. We have therefore not changed the rating for the key question Well Led as we need to see consistent good practice over time. We will check on this at our next inspection. We will be in discussion with the provider about the mutually agreed conditions on their registration and report on this at the next comprehensive inspection.

This inspection took place on 20 and 21 April 2016 and was unannounced. At the last comprehensive inspection on 11 and 12 November 2015 we had found serious breaches of regulations in respect of people’s safe care and treatment, staffing and staff training, people’s records and arrangements to monitor the quality of the service. Fourteen safeguarding alerts had been raised at the time of this inspection. Since then nine safeguarding concerns had been substantiated and two were partially substantiated. The home was rated Inadequate overall and placed in special measures. The provider placed a voluntary embargo on the home so that no new admissions were made and the home was supported by the providers’ recovery team both of which remained in place at this inspection.

We carried out this inspection on 20 and 21 April 2016 in line with our special measures policy. We checked what progress had been made in respect of addressing the breaches identified at the November 2015 inspection and also carried out a comprehensive ratings inspection.

At this inspection the home was providing nursing or residential care and support to 33 people. There was no registered manager in post. The home manager told us they had applied to become a registered manager with the Care Quality Commission. 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 this inspection we found significant improvements had been made in relation to people’s safe care and treatment. People and their relatives told us there were considerable changes in the home and were all positive about the new manager and deputy at the home. Health professionals told us there were improvements to people’s care and in staff engagement with them.

We found a breach of regulations as systems to monitor the quality of the service were not consistently operated. Staff recruitment and training records were not effectively organised or maintained to provide an accurate record of the induction and training carried out. You can see what action we told the provider to take at the back of the full version of the report.

There were some areas which required some further improvement. Staff had received recent training in a number of areas but the training the provider considered mandatory was not fully up to date and arrangements for future staff training were not in place at the time of the inspection. Care plan records required some improvement to ensure they were personalised, accurate and clear for staff to follow.

There were improvements in people’s safe care and treatment. Risks to people were identified assessed and monitored and there was guidance for staff to reduce risks. Staff knew what to do in the event of an emergency. There were enough staff to meet people’s needs. Safeguarding adult’s procedures were robust and staff understood how to safeguard the people they supported. People’s medicines were managed appropriately and they received them as prescribed by health care professionals.

Staff asked people for their consent before they provided care and demonstrated a clear understanding of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). People received a balanced diet and told us the food had improved substantially since the last inspection. People told us staff were kind and caring and treated them with dignity and respect and we observed this to be the case. They had access to appropriate health care professionals when needed.

People had an assessed plan for their care and told us they had been involved in drawing this up.

Regular residents and relatives meetings were held where people were able to talk to the manager about the home and things that were imp

We carried out a comprehensive inspection of this service on 7, 8 and 11May 2015. Several breaches of legal requirements were found. We took enforcement action and served a warning notice in respect of the more serious breaches of regulations. We carried out this unannounced inspection on 11 August 2015 to check that the more serious breaches of the regulations where we had taken enforcement action and served a warning notice had been addressed. These breaches related to risk of unsafe care and treatment in respect of the safe management of medicines and identifying and managing individual risks to people. Other breaches of legal requirements that were also found at the inspection on 7, 8 and 11 May 2015 will be followed up at a later date.

This report only covers our findings in relation to the focused inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Westcombe Park’ on our website at www.cqc.org.uk.

Westcombe Park Nursing Home accommodates up to 51 people who have nursing or residential care needs. On the day of our inspection there were 41 people using the service. There was a registered manager in place. 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 and associated Regulations about how the service is run

At this inspection we found that improvements had been made to the management of medicines. Records had been updated to show any allergies people had to medicines and competency assessments had been completed for those staff administering medicines to ensure they were competent in this role. Arrangements for the safe storage of some medicines had been improved.

However the arrangements for some people to self- administer their medicines were not always safely organised or monitored and there was a risk of possible harm. This was a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities Regulations 2014). CQC is considering the appropriate regulatory response to resolve the problems we found in respect of this regulation. These concerns were discussed with the registered manager and some steps were taken to address some of the issues at the inspection.

Individual risks to people were now clearly identified and regularly monitored. People told us they always had their call bells in reach and that staff came promptly when they called them. People were referred to health professionals such as dieticians or tissue viability nurses if required. Advice from health professionals was included in the care plan. Records to manage and track wound care healing were completed. However some records to monitor and reduce risk such as re-positional charts or food and fluid intake were not consistently completed by staff. The provider had already identified this problem and was addressing this as part of an action plan for records as a result of our comprehensive inspection in May 2015. We will follow up and check on this at the next inspection.

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People had been cared for in an environment that was safe, clean and hygienic. There were enough staff on duty to meet the needs of the people living at the home and a member of the management team was available on call in case of emergencies. Staff employed to work at the home were suitable and had the skills and experience needed to support the people living in the home.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. While no applications were required to be submitted, proper policies and procedures were in place to prevent people from being unlawfully restricted. Relevant staff were trained to understand when an application should be made, and how to submit one. We found that staff had a good understanding about adult safeguarding and they told us they would always escalate any concerns. A safeguarding policy was in place and staff attended an annual training session.

Is the service effective?

People told us that they were happy with the care they received and felt their needs had been met. It was clear from what we saw and from speaking with staff that they understood people’s care and support needs and that they knew them well. One person told us. "The home is alright. The staff are excellent. The nurses come if I ring my bell to help me.” Staff had received training to meet the needs of the people living at the home.

Is the service caring?

People were supported by kind and attentive staff. We saw that care support workers were patient and gave encouragement when supporting people. We observed this at lunch time when we saw staff assisting people at their pace and were not rushed. One person told us “they look after me, I am happy here." A visitor told us "I have no concerns about the care here; staff are very caring.” Another relative said “all the staff are brilliant.”

Is the service responsive?

People’s needs had been assessed before they moved into the home. People told us they were happy with the care they received. Records confirmed people’s preferences, history and diverse needs had been recorded and care and support had been provided that met their wishes. People had access to activities and people told us they enjoyed the social events organised by the home. We spoke to relatives who told us that the home had been responsive to feedback one relative said “they keep me informed and communicate with me if there are any changes.”

Is the service well-led?

Staff had a good understanding of the ethos of the home and quality assurance processes were in place. People told us they were asked for their feedback on the service they received and that they had also filled in an annual customer satisfaction survey. We found this had resulted in an action plan to work on improving the variety of menus and activities offered in the home. Staff told us that the acting manager had an open door policy and they could raise any issues with her. They said they had regular team meetings and they were asked for their feedback. In the annual staff survey 2013 staff rated the overall leadership effectiveness at Westcombe Park at 60%.

At our inspection on 10 April 2013 people and relatives we spoke with told us they were happy with the care they received. One person told us "staff understand my needs" and that they enjoyed the activities on offer within the home. A relative told us they "found the care to be excellent" and that their loved one "loves the food". Another relative who had previously had some concerns told us that they felt the care for their loved one had improved in recent months and that they found the manager to be approachable if they needed to discuss any issues they had.

We found that people's care was planned and delivered in a way that was intended to ensure their safety and welfare and that they were cared for by staff who were supported in their roles through training and supervision. Records maintained in the home were fit for purpose and could be located promptly when requested. People were offered a choice of nutritious food and appropriate support to ensure they ate and drank sufficient amounts to meet their needs. We also found that medicines in the home were administered safely and stored securely.

At our inspection on 22 January 2013 people told us that they were happy in the home and they felt safe and secure living there. One person told us that the staff were "patient and considerate" and that "whatever you ask for, they will get you". Another person told us that they were very happy with the care they received and that they felt supported to maintain their independence as much as possible.

We found that people were supported in promoting their independence and were cared for with dignity and respect. The provider had taken steps to identify and prevent abuse from happening within the home and peoples' needs had been assessed individually.

However, we also found some gaps in staff training and a lack of regular staff supervision. We noted concerns in the way records were maintained relating to people's care and to the administration of medication and found that care was not always being planned in line with people's assessed needs.

Overall, people told us that they were happy with the services provided by the home. People said that they had access to external health professionals, had their nutritional needs assessed and catered for, and that they felt safe living in the home.

People said that staff would ask them to make decisions about the care being provided. People told us that staff were “very kind” and responsive to their needs.

People using the service were positive about Westcombe Park Nursing Home. They said that the home was 'absolutely marvellous' and that staff were 'fine' although the home was 'sometimes short of carers and nurses because staff are very busy'.

Family members we spoke to during the visit felt that the nursing home was always 'nice and clean' and provided a 'nice atmosphere'. However some said that it would be 'nice if staff smiled a bit more'.

The home’s 2010 resident customer survey shows that overall people thought the quality of service provided was at a minimum ’quite good’. An action plan had been put in place to address areas identified as needing improvement. From resident meeting minutes, people who used the service acknowledged the improvements that the nursing home had made in relation to areas requiring attention from the survey.

This inspection took place on 11 and 12 November 2015 and was unannounced. At the last comprehensive inspection on 7, 8 and 11 May 2015 we had found serious breaches of regulations in respect of safe care and treatment in relation to risk and safe management of medicines. There were additional breaches in respect of arrangements for consent, quality assurance and treating people with respect and dignity. We also made a recommendation for the provider to review their staffing levels.

We had served a Warning Notice in relation to the more serious breaches found and followed up on these breaches at a focused inspection on 11 August 2015. Some concerns about safe care had been addressed but there were further concerns in respect of the safe management of medicines. On 24 August 2015 we imposed  urgent conditions on the provider in respect of arrangements for people who self- medicate. We set a review date for the conditions of within four months of the date the notice was served.

We carried out a comprehensive inspection on November 11 and 12 November 2015 to check if the remaining breaches from our inspection of 7, 8, and 11 May had been addressed and to provide a fresh rating for the service.

Westcombe Park Nursing Home accommodates up to 51 people who have elderly, nursing or residential care needs. There was no registered manager in place as they had left the service on 8 October 2015. An interim manager had been appointed and started at the service on 12 October 2015. This manager had previous experience of being a registered manager. 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.

Since the last inspection 14 safeguarding investigations had been raised in respect of people’s care. Two had been substantiated at the time of the inspection. Eleven of these alerts arose following concerns raised by the GP after visits to the service on 15 September 2015 and 22 October 2015. The provider had placed a voluntary embargo on new admissions following a meeting with the local authority on 16 October 2015.

At this inspection we found further breaches of regulations in respect of people’s safe care and treatment. There was a lack of communication about people’s clinical care needs. Risks to people in relation to their health and care needs were not always identified or assessed or action taken to manage the risks. Records in relation to people’s care were not accurately maintained. Systems to manage and monitor the quality of the service were not operated effectively. There were not always adequate numbers of staff deployed at the service. Arrangements to monitor the competency of nurses were not robust. There were inadequate arrangements for staff supervision and support. CQC is currently considering the most appropriate regulatory response to the concerns found and will report on this at a later date.

People told us that they felt safe and well cared for. They were positive about their relationships with permanent day staff and we observed warm and friendly interactions between staff and people using the service. However people told us they found night staff less caring. We found that the arrangements for the management of medicines had improved significantly. Staff were knowledgeable about the signs of possible abuse and what to do it they had concerns. People told us they were treated with respect and dignity by day staff and we observed some improvements had been made although there was still room for further improvement in the care provided. People had an assessed plan of care and told us they were involved in planning and reviewing their care and that their independence was encouraged. Some staff demonstrated awareness and an understanding of the people they supported and people’s individual religious and cultural needs were recognised and addressed.

Arrangements for the administration, recording and management of medicines had improved. The conditions imposed following the previous inspection had been consistently met. We have therefore reviewed our decision in respect of the conditions we imposed in August 2015, for the arrangements for people who self administer, and these have been removed from the provider's registration.

People were provided with enough to eat and drink but there were a range of comments about the quality of the food. People were asked for their consent before care was provided. Arrangements to work within the principles of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards were in place. Staff mandatory training was up to date. There was a complaints procedure in place and the provider sought feedback on the service. Residents and relatives meetings were held to communicate changes and listen to feedback, there was a suggestions box and an annual survey was carried out.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to consider the process of preventing the provider from operating this service. This may lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement and there is still a rating of inadequate for any key question or overall, we may take action to prevent the provider from operating this service. This may lead to cancelling their registration or to varying the terms of their 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.