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Westleigh Requires improvement

The provider of this service changed - see old profile


Inspection carried out on 12 August 2019

During a routine inspection

About the service:

Westleigh provides accommodation and personal care for up to 20 people who require mental health support, the service also provides support to some older people. The service is provided by Warrington Community Living, a registered charity and non-profit making organisation. There were 16 people living at the home at the time of the inspection.

Accommodation can be found across two floors; there is a communal living and dining area, well maintained garden areas and an accessible passenger lift.

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

People's support needs and areas of risk were assessed from the outset, however we found that some care records did not contain the relevant risk assessments and not all risks were effectively recorded or monitored.

Measures were in place to monitor the quality and safety of care people received but these were not always effective. We identified a number of concerns during the course of the inspection in relation to the provision of care being delivered.

Medication processes were in place; although we found that some areas of practice needed to be improved. We have made a recommendation regarding this.

People were supported to have maximum choice and control of their lives and staff supported people in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, we found one person's restrictions were not monitored as regularly as they should’ve been.

Up to date safeguarding and whistleblowing policies were in place. Staff told us how they would raise any concerns and were familiar with the reporting procedures.

Staffing levels were routinely analysed and assessed in relation to the dependency support needs of people who were living at Westleigh. Pre-employment checks were carried out and people received care by staff who had been appropriately recruited.

Staff told us they were supported on a daily basis and training, learning and development opportunities were available. Staff received regular supervision and annual appraisals.

We observed staff providing kind and compassionate care. Staff were familiar with the support needs of people who were living at Westleigh and told us how they developed positive relationships with the people they cared for.

An activities co-ordinator was employed at the home. The co-ordinator helped to arrange a variety of different group and one to one activities. Activities were tailored around people’s likes and interests.

An up to date complaints procedure was in place. People were provided with complaint information from the outset and complaints were responded to and managed in line with organisational policy.

For more details, please see the full report which is on the CQC website at

Rating at last inspection:

The last rating for this service was ‘good’ (published 01 March 2017) At this inspection we found the quality and safety of care being provided had deteriorated and the provider was in breach of regulations. The service was rated ‘requires improvement’.

Why we inspected:

This was a planned inspection based on the previous rating.


We have identified breaches of regulation in relation to safe care and treatment and good governance at this inspection.

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 with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection carried out on 21 February 2017

During a routine inspection

This inspection took place on 21 February 2017 and was unannounced. At our previous inspection in October 2015 we had concerns that people's care records were not up to date and reflective of their current care needs. We found that the systems the provider had in place to monitor and improve the service were not in use so were not effective. At this inspection we found that improvements had been made and the provider was no longer in breach of these Regulations.

Westleigh provides accommodation and personal care for up to 18 people experiencing enduring mental illness. The service is provided by Warrington Community Living, a registered charity and non-profit making organisation. There were 18 people using the service at the time of this inspection.

There was 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were being safeguarded from abuse as staff and the management team followed the local safeguarding procedures if they suspected someone had suffered potential abuse. People who used the service were encouraged to report any concerns or potential abuse.

Risks of harm to people were assessed and action was taken to minimise the risks through the effective use of risk assessment. Staff knew people's risks and followed their risk assessments to keep people safe.

There were sufficient numbers of suitably trained staff to keep people safe and meet their needs in a timely manner.

Staff had been recruited using safe recruitment procedures to ensure they were of good character and fit to work with people who used the service.

People's medicines were stored and administered safely by trained staff. Medication was regularly checked and audited.

The principles of The Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS) were being followed as the provider was ensuring that people were consenting to their care.

Staff told us and we saw they had received training and were supported to be effective in their roles.

People were supported to maintain a healthy diet dependent on their individual preferences. People received regular health care support and were referred to other health care agencies for support and advice if they became unwell or their needs changed.

People were treated with dignity and respect and their right to privacy was upheld. People were offered choices and were fully involved in the planning of their care. People were encouraged to be as independent as they were able to be.

Care was personalised and met people's individual needs and preferences. People were involved in the planning of their care and this was regularly reviewed. People's care records were clear and comprehensive and reflective of people's current care needs.

People were supported to participate in hobbies and activities of their choice within the home and local community.

People felt listened to and people's complaints and suggestions were taken seriously and acted upon.

The systems the provider had in place to monitor and improve the quality of service were effective in delivering good quality care for people who used the service.

Inspection carried out on 16 and 20 October 2015

During a routine inspection

This inspection was unannounced and took place on 16 and 20 October 2015.

This was the first inspection of Westleigh following a change of service provider.

Westleigh provides accommodation and personal care for up to 18 people experiencing enduring mental illness. The service is provided by Warrington Community Living, a registered charity and non-profit making organisation. The building is managed by Your Housing.

On the day of our inspection the service was accommodating 16 people.

At the time of the inspection there was no registered manager at Westleigh. The provider had appointed a new manager following the recent resignation of a registered manager who was in the process of applying for registration with the Care Quality Commission.

The manager was present during the two days of our inspection and engaged positively in the inspection process together with her staff. The manager was observed to be friendly and approachable and operated an open door policy to people using the service, staff and visitors.

During this inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take as the back of the full version of the report.

We found that the registered person was not operating effective systems or processes to assess, monitor and improve the quality and safety of the services provided.

We found that the registered person had not undertaken an assessment of the needs of a service user and failed to design care plans for two people with a view to ensuring their individual needs were met.

People living at Westleigh appeared relaxed and comfortable in their home environment. We found that people lived in a homely environment which was properly maintained.

The care provided was personalised and enabled people to live as independently as possible. People who used the service were supported and encouraged to follow their preferred routines and to make decisions about aspects of their daily lives. Feedback received from people using the service was very positive and confirmed that standard of care provided was good. People using the service had a choice of wholesome and nutritious meals.

Staff knew how to protect people from abuse and to keep them safe. The registered provider had policies in place to safeguard people from abuse and staff had completed training in this key area.

Medicines were ordered, stored, administered and disposed of safely. People had contact with their GP and mental health practitioners and had accessed other health professionals as required.

CQC is required by law to monitor the operation of the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS), and to report on what we find. DoLS are a code of practice to supplement the main Mental Capacity Act 2005. These safeguards protect the rights of adults by ensuring if there are restrictions on their freedom and liberty these are assessed by the supervisory body. The manager and support staff had a good understanding about this and when it should be applied.

Where complaints had been reported, these were responded to appropriately and action had been taken to resolve them. A complaints policy was in place which was also available in easy read format to make it accessible for the people who used the service.

We have made a recommendation about the need to source or develop a needs analysis and staff deployment tool. This will help demonstrate that the staffing levels at Westleigh are adequate at all times and being kept under review.