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Westhome Care Services Limited Good

This service was previously registered at a different address - see old profile

Inspection Summary

Overall summary & rating


Updated 12 February 2019

We carried out an unannounced comprehensive inspection of Westhome Care Services Limited on 21, 23, 26, 29 and 30 November 2018. At the last comprehensive inspection of the service on 24 and 27 July 2017, 24 August 2017 and 29 September 2017 breaches of legal requirements were found in relation to the person-centred care, safe care and treatment of people and the governance of the service. At this inspection the service had made the required improvements and was meeting the legal requirements.

Following the last comprehensive inspection, we asked the service to complete an action plan detailing what they would do and by when to improve the key questions of safe, caring, responsive and well-led to at least good. We saw people’s needs had been assessed regularly and these were detailed in care plans. Infection control procedures were now in place at the service and the service had a policy for staff around this. The governance of the service had improved and we saw evidence of a new governance frame work which included regular audits and documented actions taken if any issues were highlighted.

Westhome Care Services Limited is a domiciliary care agency. It provides personal care and support to people living in their own homes. It provides a service to a range of people including those living with mental health needs, dementia and physical disabilities. At the time of inspection there were 97 people using the service and 84 were receiving the regulated activity of personal care.

There was a registered manager in post who had been registered with the Care Quality Commission (CQC) to provide the regulated activity since March 2016. A registered manager is a person who has registered with the CQC 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. The registered manager submitted notifications to the Commission but we found two incidents that had not been notified to the CQC.

There was a new governance framework in place to monitor the quality and safety of the care provided to people. At the time of inspection this framework had not been fully imbedded and not all audits had been completed.

People told us that they felt safe with the care provided by staff and relatives agreed with these comments. We found there were policies and procedures in place to help keep people safe. Care files contained detailed risk assessments which were personalised, these included steps to mitigate risks around infection control, environmental risks and people’s risk of having a fall. Staff had received training and attended supervision sessions around safeguarding vulnerable adults.

Medicines were managed safely. Staff had received training around medicine’s management and had regular checks of their competencies.

Staff were safely recruited and they were provided with all the necessary induction training required for their role. The registered manager continued to provide on-going training for staff and monitored when refresher training was required. The registered manager had previous experience in a training role and delivered face to face training with all staff in a designated training room at the service’s main office. Accidents and incidents were recorded correctly and if any actions were required, they were acted upon and documented. There was an infection control policy in place and staff had received training in this.

Staffing levels reflected the needs of people using the service and visits were appropriately scheduled to meet people’s needs. Staff received regular supervision and appraisals.

The service had carried out an extensive service user quality project to ensure that the service was performing to a high standard. This included collating feedback and survey information. People and their relatives told us that they felt staff w

Inspection areas



Updated 12 February 2019

The service was safe.

People received care from staff who were trained and aware of safeguarding procedures.

Risks which people faced were assessed and reviewed regularly. There were suitable staffing levels to safely support people.

Medicines were administered safely and in line with safe medicines management procedures.



Updated 12 February 2019

The service was effective.

People received care that was delivered in line with the Mental Capacity Act (2005) MCA.

Consent was sought before staff provided care to people. People and their relatives were involved in care planning.

Staff providing care to people had received appropriate training and support to carry out their roles.



Updated 12 February 2019

The service was caring.

People were treated with kindness and respect by staff.

Staff upheld people's privacy and dignity.

People and their relatives were consulted and supported with planning their care.



Updated 12 February 2019

The service was responsive.

People received person-centred care which met their needs and was regularly reviewed and updated.

People were supported with end of life care when required.

The provider had a robust complaints procedure in place.


Requires improvement

Updated 12 February 2019

The service was not always well led.

There was a new governance framework in place that was still to be fully embedded and further work was needed in this area.

There was a registered manager in post who understood their role and responsibilities. People, staff and relatives felt that the registered manager was open and approachable.

The provider and registered manager had a clear vision, strategy and plan to deliver quality care.