About the service: Westgate House is a care home that was providing personal and nursing care to 41 older people including people living with dementia.

People’s experience of using this service:

• People living at Westgate house had a range of physical health and emotional wellbeing needs.

• Many people had dementia and had moved to Westgate House following failed placements in other care homes.

• People were not consistently cared for in a kind and caring way. Some interactions with people were at times dismissive and decisions about specific aspects of their lives had not always been made in their best interest.

• The registered manager had completed audits on the home to support quality checks. However, for some areas, these had not identified where improvements needed to be made. For example, cleanliness of the environment, care plans, risk assessments and daily records.

• There were not enough cleaning staff to maintain a safe environment.

• Medicines were managed safely, systems and processes for administration and storage of medicines were followed by staff.

• There were sufficient staff to support people in a timely way.

• The provider was committed to developing the skills and knowledge of the care team. Staff received training appropriate to the needs of the people they were caring for.

• People had good health care support from professionals. When people were unwell, staff promptly sought support from the appropriate health professionals to address their health care needs.

• Staff felt well supported by the management team and any complaints raised were effectively responded to and appropriate action was taken.

More information is in the detailed findings below.

Rating at last inspection:

GOOD (Report published 16 July 2016). At this inspection found the service had deteriorated and has been overall rated as requires improvement.

Why we inspected:

This was a planned inspection based on our previous rating.

Enforcement:

At this inspection we found the service to be in Breach of Regulation 17 Good Governance of the Health and Social Care Act 2008 (Regulated Activity) Regulations 2014. Details of action we have asked the provider to take can be found at the end of this report.

Follow up:

Following our inspection, we requested an action plan and evidence of improvements to be made in in relation to governance. We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. Should further concerns arise we may inspect sooner.

This unannounced inspection took place on the 21 June 2016. Westgate House provides accommodation and nursing care for up to 46 people with complex needs as a result of living with dementia or mental health condition. There were 38 people in residence during this inspection.

There was manager in post who was in the process of applying to be the registered manager. 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.

People were safeguarded from harm as the provider had systems in place to prevent, recognise and report concerns to the relevant authorities. Senior staff knew their responsibilities as defined by the Mental Capacity Act 2005 (MCA 2005) and Deprivation of Liberty Safeguards (DoLS) and had applied that knowledge appropriately.

There were sufficient numbers of experienced staff that were supported to carry out their roles to meet the assessed needs of people living at the home. Staff received training in areas that enabled them to understand and meet the care needs of each person. Recruitment procedures protected people from receiving unsafe care from care staff unsuited to the role.

People’s care and support needs were continually monitored and reviewed to ensure that care was provided in the way that they needed. Relatives had been involved in planning and reviewing their care when they wanted to.

People were supported to have sufficient to eat and drink to maintain a balanced diet. Staff monitored people’s health and well-being and ensured people had access to healthcare professionals when required.

People experienced caring relationships with the staff that provided good interaction by taking the time to listen and understand what people needed.

People’s needs were met in line with their individual care plans and assessed needs. Staff took time to get to know people and ensured that people’s care was tailored to their individual needs.

Feedback and complaints had been used to drive improvement in the service. The manager continually strived to find ways to improve the service through monitoring the quality of the service by regular audits.

People were supported by a team of staff that had the managerial guidance and support they needed to carry out their roles.

During this inspection, we gathered evidence against the outcomes we inspected to help answer our five key questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Below is a summary of what we found. The detailed evidence supporting our summary can be read in our full report.

Is the service safe?

We found that risk assessments identified individual risks to people's health, safety or welfare. The staff received appropriate training to ensure they had the skills and knowledge to meet people's needs.

Is the service effective?

Effective systems were in place to monitor the management of the service.

People’s care plans and risk assessments were regularly reviewed and updated as and when people’s needs changed.

Is the service caring?

Comments from people using the service were in the main positive, for example, "The staff are very good” and “I feel safe the staff know me very well”. One relative said “The carers care”.

Is the service responsive?

We saw that meetings took place with relatives to listen to their views and the provider took action to address people's suggestions for improvements. People's complaints were listened to and appropriately acted upon. We saw that people's physical and mental health was closely monitored and appropriate action was taken in seeking the advice and guidance of health and social care professionals. However one relative told us they observed staff sitting chatting together and not giving much attention to people, other than attending to basic care needs. The provider may wish to note the person said they had brought their observations to the attention of the registered manager but had not seen much improvement in the staff attitude.

Is the service well-led?

The provider and the registered manager operated an ‘open door’ policy and staff received appropriate support in order for them to do their jobs effectively. We saw that the provider regularly met with people using the service and relatives to discuss how Westgate House was meeting people's needs. The provider produced a regular newsletter to inform people using the service and their relatives about social events, communicate information and share other matters of interest.

We spoke with eight people that used the service. They mainly gave us positive comments about the care that they received. One person told us "Some carers are superb and I like the food". Another person told us "It's pretty good and I like the food".

We spoke with five relatives of people that used the service. They did not have any concerns about the service. One relative told us "The Home is perfect for my brother in law and he is looked after well, we have no concerns, in fact it is a nice location".

There was an adequate recruitment process in place. We found that people's complaints had been investigated and responded to but we were concerned that the complaints policy was not brought to the attention of people using the service or people acting on their behalf.

We found that people's basic care needs were being met but that there was a lack of stimulation for people throughout the day. We saw that people's basic dietary needs were catered for however, people were not given a choice of meals.

We were concerned about the cleanliness around the service. We found that people's independence was not being promoted and people's dignity was not being maintained. We also had concerns as people were not always offered choices about their care.

We visited Westgate House on 6 July 2012. The visit raised concerns about the management of medicines and we found the provider non compliant in outcome 9, regulation 13. People were not fully protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to record and manage medicines.

We asked the provider to send us a report setting out their actions on how they were to achieve compliance with outcome 9, regulation 13. The provider sent us an action plan on 5 October 2012 telling us what they would do to achieve compliance.

We visited Westgate House again on 8 October 2012 to check the provider had carried out the actions as set out within their action plan. We found that improvements had taken place in the storage, administration and recording of medicines.

Most of the people who lived at Westgate House were diagnosed with dementia and some people had difficulty in communicating verbally with us. We spent time during our visit observing the support people received. We saw that staff treated people with dignity and respect and made efforts to help people to make choices and decisions.

We spoke with three people who used the service who all told us they were very pleased with the care they received at Westgate House. On person said they had lived at Westgate House for a long time and they had got to know the staff very well. They told us they always felt they were treated with respect.

There were 43 people living at Westgate House when we visited on 28 February 2012. An expert by experience assisted with our visit to Westgate House. She spent time talking with three people who use the service and one relative. She had brief conversations with other people who use the service and also spent time observing day to day life in the home and the care provided to people. As many of the people living at Westgate House are unable to communicate verbally we spent an hour over lunchtime observing how staff interacted with people and also people’s state of well being.

We received mixed feedback from people about the care people receive. One person told us “It’s alright because I go out quite a lot…” another told us “It’s ok here but I also have a lovely family who visit and care for me.” And another said “, “I don’t feel too happy”. A relative told us that the staff “treat (her family member) well and feed him well”.

We observed that some staff explained to people what they were doing and talked with them while assisting them. Other staff however, did not give any explanations of what they were doing and made little attempt at any interaction or eye contact while helping people. Where staff did smile and interact we saw people respond positively.

We spoke with four people who told us that they were happy living at Westgate House. They told us that the staff were helpful. The relative of one resident told us that she was happy with the care that her family member received. Three people told us they felt safe and that they would tell the staff if they had any concerns.

This unannounced inspection took place on 20 & 24 August 2015. Westgate House provides support and nursing care for up to 46 people with dementia and mental health needs. At the time of the inspection there were 40 people living at the home.

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.

The systems and process in place for the safe administration of medicines need to improve. Administration guidance from the pharmacist was not always followed and the process of covertly administrating medication needed to be tightened.

‘You can see what action we told the provider to take at the back of the full version of the report.’

Staff generally approached people in a carefully considered way, however there were some occasions when this was not the case and where some staff did not explain what was happening to people and did not seek their consent to provide care.

Record keeping in relation to assessment, care planning, risk assessments and day to day care was in need of improvement to ensure people received personalised care and risks were identified to keep people safe.

Mental capacity assessments and Deprivation of Liberty Safeguards (DoLS) applications had been completed for people in relation to the administration of covert medicine, however were not in place for other aspects of care for those people who lacked capacity to consent to their care.

People felt safe in the home. Staff understood the need to protect people from harm and abuse and knew what action they should take if they had any concerns. Staffing levels were sufficient and ensured that people received the support they required at the times they needed. The recruitment practice protected people from being cared for by staff that were unsuitable to work at the home.

People were supported to maintain good health and had access to a range of health professionals who visited the home on a regular basis.

People participated in a range of activities both in the home and in the community and received the support they needed to help them do this. People were able to choose where they spent their time and what they did. There was a range of activities available and entertainment was brought in to the home.

People benefitted from being cared for by staff that had good relationships with the people who lived at the home. Complaints were appropriately investigated and action was taken to make improvements to the service when this was found to be necessary.

The registered manager and the home owner had good working links with other professionals and providers to learn from good practice and discuss new initiatives which improved the quality of care for people living at the home.

The manager and home owners were visible and accessible to staff and people who used the service.

People benefitted from being cared for by staff that had good relationships with the people who lived at the home. Complaints were appropriately investigated and action was taken to make improvements to the service when this was found to be necessary.