Source · CQC inspection

Westhaven

Type Social Care Org Region Yorkshire & Humberside Last inspected 29 Jan 2019

Overall rating: Requires Improvement  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Good
Well-led
Requires Improvement

Earlier inspection findings

pre-2024 framework · 2 must-do 4 should-do

Must-do actions (2)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 2
Must do
Effective
The provider must ensure decision specific mental capacity assessments are completed for people who might lack the capacity to make decisions about their care.
Regulation: Regulation 11 HSCA RA Regulations 2014 Need for consent
⚠ The provider was not completing decision specific mental capacity assessments for people who might lack the capacity to make decisions about their care.
Must-do action 2 of 2
Must do
Safe
The provider must ensure improvements are made in relation to the safe management of people's medicines, assessment of staff's competency to administer medication, updated information in people's risk assessments, and address concerns in relation to fire safety.
Regulation: Regulation 12 HSCA RA Regulations 2014 Safe care and treatment
⚠ Not enough improvements had been made in relation to the safe management of people's medicines, assessment of staff's competency to administer medication and updated information in people's risk assessments. We also found concerns in relation to fire safety.

Should-do actions (4)

Recommended improvements to enhance service quality.

Should-do action 1 of 4
Should do
Safe
The provider should consult and implement current guidance in relation to the safe administration of medicines in care homes.
Should-do action 2 of 4
Should do
Effective
The provider should consult and implement good practice in relation to consent and mental capacity assessments.
Should-do action 3 of 4
Should do
Responsive
The provider should update their complaints policy in relation to the organisation that should be contacted if complaints are not resolved by the provider.
Should-do action 4 of 4
Should do
Well-led
The provider should search and implement good practice in relation to effective quality assurance processes.

Location details

CQC ID: 1-110212875
Local authority: Kirklees
Region: Yorkshire & Humberside

Inspection report

Type: Comprehensive inspection
Date: 29 January 2019
Rating: Requires Improvement
Actions: 2 must-do 4 should-do
AI-extracted 17 Feb 2026