This unannounced inspection took place on 14 & 15 June 2018. Westlands Retirement 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.

Westlands Retirement Home is registered to provide personal care and support for up to 20 older people some of whom may be living with dementia or physical frailty. The home does not provide nursing care; people living there would receive nursing care through the local community health teams.

On the afternoon of 14 June 2018, the provider informed us they had admitted another person for planned respite care. The person was admitted to a vacant room, which had previously been registered. We explained to the provider that they were in breach of a condition of their registration and asked them to send the required notification, which they did. This meant there were 21 people living at the home and the provider was in breach of a condition of their registration. The home is now registered to provide accommodation and support for up to 21 people.

The home did not have a registered manager at the time of the inspection as the registered manager had recently retired. A new manager had been appointed; they had applied to become registered with the Care Quality Commission and were available throughout this inspection. They are referred to as the manager throughout this report. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run.

We looked at the home’s quality assurance and governance systems to ensure procedures were in place to assess, monitor, and improve the quality and safety of the services provided. Although some systems were working, others had not been effective, as they had not identified the concerns we found during this inspection.

People were not always protected from the risk of avoidable harm. We found risks such as those associated with people's complex care needs, medicines, recruitment and the environment had not always been assessed or managed safely. Where risks had been identified, guidance had not been provided to staff to mitigate these risks. Although systems were in place to identify and record accidents incidents, there was no consistent system in place for analysing and identifying patterns to prevent a reoccurrence.

Whilst some premises checks had been completed we noted others had not, we found a number of bedroom windows were not risk assessed so the provider could not judge if they were properly restricted, and safe. There was no evidence the provider had carried out any form of risk assessment in relation to needs of people currently living at the home and the risks posed by having unrestricted windows that were accessible.

People were not always supported by staff that had the necessary skills and knowledge to meet their needs. Records showed that staff inductions, supervisions, and annual appraisals were poorly documented. There was not an effective system in place to ensure staff were provided with the necessary training and support to meet the needs of the people they supported.

People’s needs were assessed prior to coming to live at the home. This formed the basis of a care plan, which was further developed after the person moved in and staff had gotten to know the person better. We found people were at risk of receiving care that did not meet their needs as some people’s care plans contained outdated or misleading information. None of the care records we saw were being regularly reviewed or updated in line with homes expectations.

People received their prescribed medicines on time and in