Background to this inspection
Updated
6 June 2023
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was carried out by 1 inspector, 1 medicines inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Withins (Breightmet) Limited is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Withins (Breightmet) Limited is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with 7 staff including the deputy manager, the care manager, senior care staff and care staff and the registered manager who was also the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We spoke with 2 visiting health care professionals, 3 people and 10 relatives about their views of the care provided. We reviewed the care records for 6 people across the 3 units of the home, numerous medicines records, 6 staff recruitment and supervision files, records related to governance systems and processes and other documentation relevant to the running of the service.
Updated
6 June 2023
About the service
Withins (Breightmet) Limited is a residential care home providing personal care for up to 65 people in one purpose-built building over three floors, including autistic people and people with a learning disability. There are 22 bedrooms on the lower ground floor, 32 bedrooms on the ground floor, and 11 bedrooms on the first floor. All bedrooms have ensuite facilities with communal lounges, bathrooms, and dining rooms. During the inspection there were 64 people using the service. There is access to secure outside terraces or gardens on all floors.
People’s experience of using this service and what we found
We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
Right Support:
The provider was not always ensuring risks were assessed and mitigated effectively and medicines were not always managed safely. Documents with regard to medicines were not always complete and accurate. Audits in place were not always robust enough to identify and address the issues found during the inspection with the safe management of medicines. We have made a recommendation about medicines audits.
Staffing levels were sufficient to meet people's needs and managers recruited staff safely. Staff followed an induction programme, and training was on-going throughout employment. Staff thoroughly assessed people's needs prior to a service starting. Care plans included information about support required in areas such as nutrition, mobility, and personal care to help inform care provision. Staff made appropriate referrals to other agencies and professionals when required.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People were supported by staff to pursue their interests and staff supported them to achieve their aspirations and goals. People had a choice about their living environment and were able to personalise their rooms.
Right Care:
Care was person-centred and promoted people’s dignity, privacy, and human rights. Staff promoted equality and diversity in their support for people and understood people’s cultural needs and provided culturally appropriate care. People received kind and compassionate care. Staff protected and respected people’s privacy and dignity and understood and responded to their individual needs. Staff understood how to protect people from poor care and abuse. The provider worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
People’s care plans reflected their range of needs, and this promoted their wellbeing and enjoyment of life. People could take part in activities and pursue interests that were tailored to them. The service gave people opportunities to try new activities that enhanced and enriched their lives. People told us they were well treated, and their equality and diversity were respected. People felt staff respected their privacy and dignity and took into account their views when agreeing on the support required. Staff identified people's communication needs and addressed these with appropriate actions.
Right Culture:
People led inclusive and empowered lives because of the ethos, values, attitudes and behaviours of the management and staff. Staff knew and understood people well and were responsive, supporting their aspirations to live a quality life of their choosing. Staff turnover was very low, which supported people to receive consistent care from staff who knew them well. The ethos, values, attitudes and behaviours of leaders and care staff ensured people led confident, inclusive, and empowered lives.
Staff placed people’s wishes, needs, and rights at the heart of everything they did. People and those important to them, including advocates, were involved in planning their care. Staff evaluated the quality of support provided to people, involving the person, their families, and other professionals as appropriate
People’s quality of life was enhanced by the service’s culture of improvement and inclusivity. Staff ensured risks of a closed culture were minimised so that people received support based on transparency, respect, and inclusivity.
Managers responded to complaints appropriately and used these to inform improvement to care provision. The provider was open and honest, in dealing with concerns raised. The provider and registered manager followed governance systems which provided effective oversight and monitoring of the service. These governance systems and processes ensured the service provided to people was safe, however medicines monitoring systems needed improving.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 23 June 2022) and there were breaches of regulation.
The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations. This service has been rated requires improvement for the last 2 consecutive inspections.
Why we inspected
We carried out an unannounced focused inspection of this service on 17 May 2023 and 23 May 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe and well-led which contain those requirements. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. We found the provider remained in breach of regulations.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Withins (Breightmet) Limited on our website at www.cqc.org.uk.
Enforcement
We have identified a breach in relation to safe care and treatment. Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.