Archived: 20 Westwood Avenue

Updated 29 November 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service and provide a rating for the service under the Care Act 2014.

The inspection team consisted of one inspector. Before we visited the home we checked the information we held about the service and the service provider including notifications and incidents affecting the safety and well-being of people. No concerns had been raised.

There were three people using the service. All the people had learning disabilities and could not always communicate with us and tell us what they thought about the service. Because of this, we spent time at the home observing the experience of the people and their care, how the staff interacted with people and how they supported people during the day and meal times.

We spoke with one relative. We also spoke with the provider, registered manager, two care workers and a visiting healthcare professional. We reviewed three people’s care plans, four staff files, training records and records relating to the management of the service such as audits, policies and procedures.

Updated 29 November 2016

We undertook an unannounced inspection on 11 October 2016 of 20 Westwood Avenue. 20 Westwood Avenue is registered to provide accommodation and personal care for up to three people with learning disabilities. At the time of this inspection, three people were using the service.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission [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.

At our last inspection on 20 October 2015, we found breaches of legal requirements in relation to Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found the assessment of risks to the health and safety of people using the service was not being done appropriately. Complete and contemporaneous records were not maintained in respect of the care and treatment provided to people using the service and quality assurance systems were not effective in to monitor the quality of the service being provided to people who used the service. The service was rated as requires improvement.

Following the inspection the provider sent us an action plan setting out the actions they would take to meet the regulation. During this inspection we found action had been taken to meet the regulations. Records showed the registered manager had taken appropriate action to review and update people’s care plans and risk assessments to accurately reflect people’s needs. Care plans were individualised and person- centred. The service undertook a range of checks to monitor the quality of the service and took action to improve the service. A satisfaction survey had been carried out in April 2016 and the results from the survey were positive.

Relatives informed us that they were satisfied with the care and services provided. Relatives also told us that they were confident that people were safe in the home.

Systems and processes were in place to help protect people from the risk of harm and staff demonstrated that they were aware of these. Staff had received training in safeguarding adults and knew how to recognise and report any concerns or allegations of abuse.

Systems were in place to make sure people received their medicines safely. Arrangements were in place for the recording of medicines received into the home and for their storage, administration and disposal.

We found the premises were clean and tidy. There was a record of essential maintenance carried out at the home. However we noted and discussed with the registered manager the décor of the home as it contained basic furnishing and there was a need for improvement. The registered manager told us she would address these matters. Shortly after the inspection, we were told by the registered manager that a decorator had been called and work had already commenced in the home.

Staff had been carefully recruited and provided with induction and training to enable them to support people effectively. They had the necessary support, supervision and appraisals from management.

Staff we spoke with had an understanding of the principles of the Mental Capacity Act (MCA 2005). Capacity to make specific decisions was recorded in people's care plans.

The CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The home had made necessary applications for DoLS as it was recognised that there were areas of people’s care in which people’s liberty was being deprived. Records showed that the relevant authorisations had been granted and were in place.

There were suitable arrangements for the provision of food to ensure that people's dietary needs were met.

Staff were informed of changes occurring within the home through daily handovers and staff meetings. Staff told us that they received up to date information and had an opportunity to share good practice and any concerns they had at these meetings.

There was a management structure in place with a team of care workers, registered manager and the provider. Staff spoke positively about working at the home. They told us management were approachable and the service had an open and transparent culture. They said that they did not hesitate about bringing any concerns to the registered manager.

Relatives spoke positively about management in the home and staff. They said that the registered manager was approachable and willing to listen.