West Lodge Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We identified one breach of the legal regulations. The scores for these areas have been combined with scores based on the rating from the last inspection, which was requires improvement. Though the assessment of these areas indicated areas of concern since the last inspection, our rating for the key question remains requires improvement. People's needs and rights were not always supported. People's care and treatment was effective due to their health, care, well-being, and communication needs not being assessed with them. People's care plans were not always kept up to date with any assessments completed in a timely manner. People were not aware of their rights around care and treatment. Staff did not have good knowledge of the mental capacity act, including capacity and consent. We have taken action and asked the provider to make improvement.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were not able to explain how they were involved in assessing their care and support needs. People had not been given the opportunity to have a holistic review of their physical, mental and support needs. This meant people were at risk of not receiving the best possible outcomes.

The registered manager acknowledged their initial assessment process required improvement. They had recently reviewed their process and made changes from telephone assessments to face to face assessments.

Care plans and assessments demonstrated people were not involved in assessing their care and support needs. Care plans and assessment were reviewed monthly. However, the reviews were ineffective, staff had not identified that care plans were not reflective of people’s needs and not always identified people’s needs had changed. For example, a person sustained a burn from a hot drink, we found the care plan or a risk assessment had not been updated. People’s communication needs were recorded and understood by staff. This allowed staff to communicate with people, to have a clear understanding of the persons needs

We observed people where offered a choice of meal during lunch time. Throughout the assessment staff offered people drinks or a fresh drink.

The management team knew people well and told us about people’s dietary needs and preferences. Any concerns about people’s food and fluid intake staff would report this to the nurse in charge or registered manager. Staff understood how to work with external health and social care providers, to provide support in the most effective way.

People’s nutrition and hydration needs were supported in line with current standards. Staff had identified people at risk of weight loss and there was a system in place to monitor their weight. Where needed, staff had supported people to source additional weight gaining supplements. Care plans were not always updated to show up to date information about the risks of weight loss.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We found staff record keeping was not always accurate and reflective of what had happened. For example, during the onsite assessment on 1 October 2024, daily records for a person describe them as being content. However, we observed the person to be unsettled for most of the day. This meant their care records were not reflective of their presentation and needs. This would make it difficult to effectively monitor or make the necessary improvements to the person’s care. People told us there was not much for them to participate in. One person told us, “There is no entertainment. ‘We just sit down and fall asleep after lunch. There is nothing to do.” Another person told us, “You can play bowling, they [staff] could do with bringing in one or two more games.” Relatives told us the care home staff and health professionals worked together and kept relatives informed if needed. One relative told us, “Staff do contact me if something has happened, or if my loved one needs anything. This includes if they contact the doctor.”

The provider told us they visit regularly and ensure they are monitoring peoples outcomes and people are receiving good quality care. However, there was no record of these visits and what was monitored and what action had been taken to improve the service. The registered manager told us they complete a management daily walk around to identify any risks or concerns. There was no record of this check being completed and during our visit we found multiple concerns. Therefore, we were not assured these checks were effective.

There was no process in place for people or relatives to discuss their care and review what was working well and what needed to improve. People were not empowered to share their goals and wishes so that they could be supported to achieve these to promote good outcomes for people. There was not a system in place to have clear oversight of the service.

Where people were deemed to lack capacity to make decisions, the management team had not always followed the Mental Capacity Act. Relatives were not always involved in the best interest decisions and processes. People had not been involved in their care planning and risk assessment, therefore could not have consented to their care plans. We were not assured people were supported to understand their rights around consent and care the provider offered.

The registered manager told us they were aware the mental capacity assessments were not thorough or completed to the necessary standards. However, the registered manager or provider did not have any plans or timescales for when this would been actioned. This meant people living at West Lodge Care Home that required a best interest decisions did not have the specific decision in line with the Mental Capacity Act.

People who did not lack capacity had care plans which did not demonstrate consent had been obtained or shared with people to ensure they had consented to their information to be shared with the staff team. This meant people could be deprived of their liberty or care carried out with or for them, without consent. The Mental Capacity Act 2005 (MCA) provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take decisions, any made on their behalf must be in their best interests and as least restrictive as possible. We found The Mental Capacity Act was not always followed. We found where people had lacked capacity to consent, the best interest process had not always been followed. Relatives had not always been involved in the decision-making process. This meant people were at risk of having best interest decisions made without considering their wishes, beliefs and values. Some people were subject to Deprivation of Liberty Safeguard authorisations (DoLS). Where people were subject to DoLS with conditions, there was poor oversight to ensure the condition(s) were clearly reflected in care planning documents. This meant staff may not understand applied conditions. A person had conditions attached to their DoLS stating they should be supported to access the community. However, this conditions was not met. This further restricted the persons liberty by not adhering to the conditions. For people who did not have family, friends, or someone important to them to advocate for them, the registered manager did request an advocate where appropriate.