Archived: Avenues South East - 4 Westhall Park

Updated 24 December 2022

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 two inspectors.

Service and service type

Westhall Park 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. Westhall Park 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 not a registered manager in post.

Notice of inspection

This first day of this inspection was unannounced. We announced our second visit to the service on 8 November 2022 to meet with the manager who was not present on our first day.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used information gathered as part of monitoring activity that took place on 1 August 2022 to help plan the inspection and form our judgements.

We used all this information to plan our inspection.

During the inspection

People living at the service were not able to speak with us, therefore we used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We spoke with seven staff, this included the nominated individual, the operations project manager who had been overseeing management of the service since January 2022, a supporting manager, the senior operational manager and support workers. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We spoke with four relatives following our inspection.

We reviewed four care plans in varying detail, medicines records and other records relating to the running of the service. Following our inspection, the supporting manager sent us requested information relating to staff training, supervision, meetings and audits. We also received information from the registered provider’s regional director.

Updated 24 December 2022

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.

About the service

Avenues South East – 4 Westhall Park (referred to as ‘Westhall Park’ in this report) is a residential care home providing accommodation and personal care for up to six people with autism and/or a learning disability. At the time of the inspection five people were living at the service which is a converted house in a rural area with its own garden.

People’s experience of using this service and what we found

Right Support:

There was the potential that people could come to harm as staff did not always have access to training to support them in caring for people with specific needs. We have issued a recommendation to the registered provider in relation to this. There was little evidence to show that staff were supporting people to learn new life skills or giving people the opportunity to increase their independence.

People were cared for by a sufficient number of staff whilst indoors, but there were not enough staff on a regular basis to enable people to go out into the community or participate in new activities.

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.

Right Care:

People’s care was not always person-centred; care that focused on the person and their individuality. Some staff did not always demonstrate a respectful approach, communicate or provide information to people in a way they understood. Although we saw some nice occasions when staff engaged with people in a kindly way.

People lived in an environment that required redecoration and refurbishment, although their individual rooms were personalised.

People received the medicines they required and relatives said they felt their family members were safe living at Westhall Park. Staff understood what constituted potential abuse and knew how to report this.

Right Culture:

There had been a lack of registered manager at the service, although the operations project manager had made some improvements to the service since they had been on site.

There were occasions when staff were seen not wearing their masks correctly and we spoke with management about this.

Staff told us they felt supported by their managers and they had the opportunity to meet with them on a one to one basis for supervision.

The registered provider, prior to our inspection, had recognised the shortfalls in the service and had already made the decision to close the service within the next two months. They were working closely with the local authority to find alternative homes for people to move to.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good (published 2 March 2018)

Why we inspected

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk. This inspection examined those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We found no evidence during this inspection that people were at immediate risk of harm. Although, we identified that not all staff were given appropriate information about people prior to caring for them.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to person-centred care, respect and good governance. We have also made a recommendation to the registered provider around supporting people’s independence and additional training for staff.

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.