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West End Village Requires improvement

The provider of this service changed - see old profile

We are carrying out a review of quality at West End Village. We will publish a report when our review is complete. Find out more about our inspection reports.


Inspection carried out on 14 April 2021

During a routine inspection

About the service

West End Village is a domiciliary care service and extra care housing service providing personal care to 30 people aged 55 and over at the time of the inspection.

People using the service lived both in a large gated community in Stoke-on-Trent and also lived in ordinary houses and flats across Stoke-on-Trent. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

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

People were not always supported to transfer by the number of staff required to meet their needs, placing people and staff at risk of harm. Staff did not always complete Medicine Administration Records (MARs) correctly which meant we could not be assured that medicines were administered safely and as prescribed.

Systems in place to allocate staff failed to ensure sufficient staff were assigned to meet people’s needs safely. Audit systems in place were not always effective in checking the quality of the service. The culture of the service was not positive and did not promote good outcomes for people.

Staff did not consistently deliver effective care in line with people’s care plans. People were not always supported by staff who were caring and empathetic towards them.

Accidents and incidents were recorded and action was taken when needed to reduce the risk of reoccurrence. Staff knew how to prevent and control infection and regular competency checks were undertaken.

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. People were supported by staff who were sufficiently trained to meet people’s needs and their competencies were checked regularly. People were supported to access healthcare professionals when needed.

People were supported to express their views and were encouraged to make decisions about their care. People were supported by staff who respected their dignity and promoted their independence.

People’s preferences were documented in care plans and staff knew people well. People’s communication and sensory needs were considered when planning and providing care. A complaints policy was in place and this was followed.

Staff feedback was obtained via social media groups and through questionnaires so the service could be improved. The management team were proactive in improving care where needed and changes were implemented where needed.

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

Rating at last inspection

The last rating for the service under the previous provider was Good, published on 10 February 2017.

Why we inspected

The inspection was prompted in part due to concerns received about infection control. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective, Caring, Responsive and Well-Led sections of this full report.

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

The provider has taken immediate action to mitigate the risks but these new systems have not been embedded for long enough for us to determine if they are effective.


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.

We have identified breaches in relation to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulat