The Care Quality Commission
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Archived: Westleigh Residential Care Home

Overall: Requires improvement read more about inspection ratings

46-48 Osborne Road, Levenshulme, Greater Manchester, M19 2DT (0161) 257 2981

Provided and run by:
Mrs Elizabeth Heather Martin

All Inspections

17, 18 March 2015

During a routine inspection

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.

23 May 2014

During a routine inspection

This inspection was carried out by one inspector. We met with twelve people who used the service and observed their experiences of care to support our inspection. We spoke with the registered manager, four staff, three relatives and one healthcare professional.

In this report the name of a registered manager appears who was not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

We considered our inspection findings to answer questions we always ask:-

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

Below is a summary of what we found. If you want to see the evidence that supports our summary, please read the full report.

Is the service safe?

We found that people who came to live at the home had an assessment of their needs completed before they moved in; this ensured that their needs could be met by the home.

We found shortfalls in the legibility, accuracy and security of care records. This meant that people were at risk of unsafe or inappropriate care and support.

People told us that they were happy living at the home and were supported to remain independent as safely as possible. They also told us that they felt their needs were met because staff supported them.

People were cared for in an environment that was not clean and hygienic.

The registered manager had suitable arrangements to safeguard people from foreseeable emergencies.

We saw that staff had not always used wheelchairs appropriately and in a safe way and that accidents had not always been correctly reported.

There was no one who lived at the home subject to deprivation of liberty safeguards. We noted that staff had not always recorded where a best interest decision had been made.

People told us that they felt safe living at the home and their relatives confirmed this. We saw safeguarding procedures were in place and that staff understood how to safeguard the people that they supported. People were protected against the use of unlawful or excessive control or restraint because the provider had made suitable arrangements, although we found that best interest decisions were not always recorded.

There were audits completed to make sure that the building and procedures were maintained.

Is the service effective?

All of the people we spoke with and their relatives, told us that they were happy with the care that was delivered and their needs were met.

Activities were provided by the staff working in the home, and we saw an advertisement on the notice board for future events. One relative told us, 'They (relative) go out every week.'

We noted some concerns with the ability of some of the people living at the home to be able to watch television when using the lounge areas.

We saw staff displaying a good understanding of the people they cared for. During observations, we heard staff reminiscing with one person which the person clearly enjoyed doing.

Staff had received training to meet the needs of the people who lived at the home, although we noted some gaps.

Is the service caring?

We asked twelve people if they had any concerns about the care provided by the home and those that were able, told us that were happy with the care provided and that the staff were caring. One relative told us, 'We have nothing but praise and have no complaints whatsoever.'

Observations during the visit showed staff were compassionate and caring to the people they supported. We saw staff responding quickly to people who required support.

Is the service responsive?

Information was collected by the service with regard to the person's ability and level of independence. Regular reviews were carried out to make sure the person's care and support needs had not changed.

Meetings took place with staff to discuss the running of the service and to ensure the service was responsive in meeting the changing needs of people who used the service.

There had been specialist advice given to one person who lived at the home, which had not been fully adhered to by the staff.

Surveys were completed with people, their representatives and visitors to the home and staff acted on comments made.

We noted some concerns over the regime for personal care and breakfasts at the home.

Is the service well-led?

There was a registered manager in post.

People who used the service had regular contact from the registered manager and other senior staff to check their wellbeing. The quality of service provided by care givers was monitored and this was done through quality audits.

Staff were knowledgeable about the support needs of people and the services ethos of maintaining safe independence and involvement of the person whatever their level of need.

One relative told us that they had been impressed by the level of communication they had received since their relative had moved into the home. They told us, 'If there is any query over care, the staff ring me.'

10 April 2013

During a routine inspection

People living at Westleigh Residential Care Home (and their visitors) told us that they were being cared for and supported properly. They also told us that staff respected their privacy and maintained their dignity. Comments made included:

'I am treated with respect and feel that the staff have helped me enormously to keep as independent as I can be.'

'I am well cared for. The staff help me to do the things I am not able to do for myself anymore.'

'I feel that I have been looked after really well. I have lived here for a long time and when I have been ill they get the doctor and send you to hospital if needs be.'

'My [relative] has difficulty with their memory. The staff here have consulted and involved me about all aspects of my [relative's] care.'

We found that people were being cared for in a suitable environment by adequate numbers of appropriately trained staff. A suitable system to monitor the quality of the services provided was being operated.

14 May 2012

During a routine inspection

People living at Westleigh Residential Care Home told us their dignity was respected and that staff were polite and kind. They were also of the view that the care and support they were receiving was safe and appropriate and that they were treated as an individual. Regular visitors to the home told us that, in their view, staff were caring for and supporting people properly.