Archived: Westleigh Residential Care Home

Updated 8 September 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on the 17 and 18 March 2015 and was unannounced. The inspection team included two adult social care inspectors 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. The expert by experience had experience of older people’s services.

We reviewed all the information we had available whilst planning for this inspection.

Before our inspection, we reviewed the information we held about the home, requested information from Manchester Council and sourced information from other professionals who worked with the home. During the inspection we spoke with nine staff including the registered manager, deputy manager, senior carers and carers. We also spoke with the chef and the laundry and domestic staff. We spoke with three visiting professionals including a consultant psychiatrist and a GP. We spoke with 10 people who lived in the home and five visitors.

We observed how staff and people living in the home interacted and we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We observed support provided; in the communal areas including the dining room and lounges during lunch, during the medication round and when people were in their own room. We looked in the kitchen, laundry and staff office and in all other areas of the home.

We reviewed seven people’s care files and looked at care monitoring records for personal care, body maps used to monitor injuries and accident records. We reviewed medication records, risk assessments and management information used to monitor and improve service provision. We also looked at meeting minutes where available and five personnel files.

Updated 8 September 2015

We carried out an inspection of this service on 17 and 18 March 2015. The inspection was unannounced. This means the service did not know when we would be undertaking an inspection.

The home was last inspected in May 2014 when breaches of the regulations were found. We checked at this inspection to see that action had been taken to meet the regulations.

Westleigh Residential Care Home is a large three storey detached property in a residential area of Levenshulme, Greater Manchester. The home provides residential care and support for up to 26 people. At the date of the inspection 24 people were living in the home. The home had a large communal lounge on the ground floor with smaller communal areas on other floors. The kitchen and laundry facilities were in the basement area of the building as was the dining room. All floors were accessible by a lift and stairs.

The home 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 a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

Following the inspection in May 2014, the provider sent us an action plan to say how they would meet the regulations. We used the action plan provided to ascertain if the work had been completed.

During this inspection we found staff were competent in safeguarding procedures and keeping people safe. People we spoke with all told us they felt safe living in the home.

We saw that staff were recruited safely and equitably. The correct checks were made to ensure staff were suitable for the role they had applied for before they were appointed.

When reviewing people’s care plans we found assessments had not been reviewed for two or more months. We found risk assessments and risk management plans had not been completed when risks had been identified. This is a breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to Regulation 12 (1) (a) and (b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Whilst we found medicines were administered correctly, records were not always accurate. We found an audit had not been completed on medicines for over 12 months and staff were not identifying errors. Staff had not received required training, and medicines to be disposed were not recorded in a timely manner. This is a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to Regulation 12 2 (g) of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014.

Westleigh Residential care home was in need of refurbishment and redecoration. Some of these aspects impacted on the cleanliness and security of the building. We found sluice rooms were not fit for purpose and security and fire doors did not fit into their frame leaving a risk of inadequate protection in the event of a fire. We found the provider in breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to Regulation 15 (1) (a) (c) (e) (2) Of the health and social Care Act 2008 (Regulated Activities) Regulations 2014.

People we spoke with who lived in the home, spoke positively about the staff.

Staff were supported formally and informally. Staff and people who lived in the home worked together to improve the service including the establishment of a health and safety committee.

Staff were unclear on the requirements under the Mental Capacity Act 2005 (MCA) specifically around restrictive practice and capacity. The manager was aware assessments to support the use of bedrails needed to be completed before consent was acquired. If people were assessed to be unable to give consent themselves then procedures needed to be followed in line with the MCA. On the day of the inspection correct procedures were not being followed resulting in a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Food was plentiful, well presented and home cooked. There was little waste at the end of the observed lunchtime service. We saw snacks and drinks being offered throughout the day and everyone we looked at was of a healthy weight. When people did not eat well at a designated mealtime they were provided with food at a time to suit them. Staff - were attentive and respectful when supporting people with their meals and their needs. Staff took their time when supporting people and things did not appear rushed.

On the day of the inspection we saw two visiting professionals who were both very complimentary about the home.

Another told us about a trip they had to a local shopping complex and how much they enjoyed it.

Two people also told us, they would like more to do. The registered manager told us a new activities co-ordinator was due to start work at the home.

We saw some good examples of person-centred care being delivered. For example, one person’s meal time plan identified the person liked to sit in a specific place and this was accommodated whenever possible. One person preferred to be bathed by a female member of staff and we saw from records that this happened. Another person visited Age Concern three times a week as they had done when they lived in their own home and people attended a monthly Catholic service that was held in the home if they chose to.

When reviewing care plans we noted reviews were not always recorded and changes were not always reflected within plans of care. This is a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to Regulation 9 (1) and 9(3) (a) Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

A member of staff took time each month to ask every resident if they were ok or if anything needed to be changed. This was recorded as part of the resident meetings.

We were told favourable things about the home from everyone we spoke with. Staff told us they were well supported and visiting professionals told us they directions were followed when supporting people in the home.

However we found occasions when records were not kept in a way to ensure suitable standards were maintained. Comprehensive audits were not undertaken to identify concerns before they arose. Information was not analysed or monitored to ensure people remained in receipt of appropriate care. The lack of effective systems to assess and monitor the service and incomplete records is a breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2010 which corresponds to Regulation 17 (1) (2) (a) (b) (c) of the Health and social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see the action we have asked the provider to take at the back of this report.