Archived: Westwood House

Updated 11 September 2015

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 to provide a rating for the service under the Care Act 2014.

We undertook an announced focused inspection of Westwood House 28 August 2015. This inspection was undertaken to ensure that improvements that were required to meet legal requirements had been implemented by the service following our last inspection on 07 April 2015.

We inspected the service against two of the five questions we ask about services during an inspection, which was whether the service was ‘effective’ and ‘well-led.’ This was because the service was not meeting some legal requirements.

The inspection was undertaken by an adult social care inspector. Before the inspection, we reviewed all the information we held about the home. We reviewed statutory notifications and safeguarding referrals. We also reviewed the action taken by the provider following our last inspection, who wrote to us on 03 June 2015 explaining what action the service had taken to meet legal requirements.

During the inspection we spoke with the registered manager and a member of administrative staff. We also looked at records relating to supervision and audits that had been undertaken by the service to monitor the quality of service provision.

Updated 11 September 2015

We carried out an announced comprehensive inspection of this service on 07 April 2015. During that inspection we found two breaches breach of Regulation under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in to relation to staffing and good governance. After that inspection, the provider wrote to us to tell us what action they had taken to meet legal requirements in relation to the breaches of regulation.

As part of this focused inspection we checked to see that improvements had been implemented by the service in order to meet legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Westwood House on our website at www.cqc.org.uk.

Westwood House is a domiciliary care service based at Salford Quays, Manchester. It provides personal care for a range of people living at home. The service provides supported living; community based home care and 24 hour care packages for complex health care needs, challenging behaviour and/or autistic spectrum disorder.

There was a registered manager in place. 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.

This inspection was undertaken on 28 August 2015 and was announced. During our last inspection, we looked at the training, learning and development needs of individual staff members. We found limited information that formal supervision and appraisals had been undertaken. We looked at the staff supervision policy, which indicated formal supervision would take place at least once in every quarter. From reviewing records we found this was not happening. This was a breach of Regulation 18 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to staffing, because staff did receive appropriate on-going or periodic supervision and regular appraisals to support them in their role.

During this inspection we found the provider was now meeting the requirements of the regulation. We found that regular supervision had now been undertaken by the service. We looked at 12 supervision records for different members of staff. We were told that in line with policy, supervision would take place three times a year, unless more were required. We saw that supervision was managed effectively by use of a supervision monitoring form. The registered manager told us that an annual appraisal system had been introduced and was scheduled to commence next month for all staff members.

During our last inspection, we found the service did not have systems and processes to effectively monitor and improve the quality of services provided. The service was unable to demonstrate how they regularly sought the views of people who used the service and took regard of any complaints, comments and views made. This was in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to good governance. The registered person did not have appropriate arrangements in place to monitor the quality of service or regularly seek the views of people who used the service.

During this inspection we found the provider was now meeting the requirements of the regulation. We looked at a number of audits that had been undertaken by the service to monitor the quality of service delivery. These included weekly and monthly medication audits. The service had introduced a system of ‘spot checks,’ which covered staff competency to engage with people who used the service effectively, the quality of care files and that records were accurately maintained.

The registered manager told us that they were due to circulate questionnaires to people who used the service during September 2015 as an annual means of monitoring the quality of service provision. Questionnaires would also be circulated to relatives and health care professionals. At the time of our visit, the service provided support to 19 people living in their own homes. The service was able to demonstrate how they electronically maintained records of all contacts with people who used the service. This included any concerns or issues raised by people who used the service and recorded what action had been taken by the service to address the issue. We also looked at the service complaints and compliments policy, which provided clear instructions to staff as to what action take in the event of a formal complaints made against the service.