We inspected Westhope Mews on 18 November 2016. We previously carried out a comprehensive inspection at Westhope Mews on 3 and 4 August 2015. We found the provider was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because we identified concerns in respect to the management of medicines, the assessment of risks, safeguarding practices, recruitment documentation and quality monitoring. The service received an overall rating of ‘requires improvement’ from the comprehensive inspection on 3 and 4 August 2015. After this inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to these breaches.

We undertook this unannounced comprehensive inspection to look at all aspects of the service and to check that the provider had followed their action plan, and confirm that the service now met legal requirements. We found improvements had been made in the required areas. Improvements had been made and the overall rating for Westhope Mews has been revised to good.

Westhope Mews is registered to accommodate up to eight people. It specialises in providing support for people who have a learning or physical disability. At the time of our inspection there were seven people living in the service.

There was a manager in post, however they had not yet applied to become the registered manager of the service, and at the time of our inspection, they were not registered with the CQC. 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 staff we spoke with were aware of their role in safeguarding people from abuse and neglect and had received appropriate training. We saw risk assessments had been devised to help minimise and monitor risk, while encouraging people to be as independent as possible. Staff were very aware of the particular risks associated with each person’s individual needs and behaviour.

Medicines were managed safely and in accordance with current regulations and guidance. There were systems in place to ensure that medicines had been stored, administered, audited and reviewed appropriately.

The service asked people and other stakeholders to fill in surveys about the quality of the service and people’s feedback was included in plans for future improvements. There were effective systems in place for monitoring the quality and safety of the service. Where improvements were needed, these were addressed and followed up to ensure continuous improvement.

People were happy and relaxed with staff. They said they felt safe and there were sufficient staff to support them. One person told us, “Yes I feel safe and I am happy here”. When staff were recruited, their employment history was checked and references obtained. Checks were also undertaken to ensure new staff were safe to work within the care sector.

People’s needs had been identified, and from our observations, people’s needs were met by staff. Staff used touch as well as words and tone to communicate with people in a positive way. There was positive interaction between people and the staff supporting them. Staff spoke to people with understanding, warmth and respect and gave people lots of opportunities to make choices. The staff we spoke with knew each person’s needs and preferences in detail, and used this knowledge to provide tailored support to people.

We found the service to be meeting the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The staff we spoke with had a good knowledge of this.

People were supported to eat and drink sufficient to maintain a balanced diet. One person told us, “I like the food, it’s nice. We get what we want and have me

We spoke with five people living at Westhope Mews during our visit. They were satisfied with the service provided. One said, “Westhope’s all right” and, “The staff are great”. Another told us, “This is our home and that’s it”.

We spoke with three relatives. They were all complimentary about the home and staff. One said, “The staff are really friendly and very helpful” and, “They’re learning to read X (their relative) really well”. Another told us, “I’m really pleased, X is happy as Larry”.

We also gathered evidence of people's experiences of the service by observing how people were supported by staff, looking at records and talking with members of staff and the manager. We found that people's care needs were being managed safely by the service and that staff had a good understanding of their roles and responsibilities in this area.

We found that the support people received was individualised to their needs. People's rights with regard to consent were being promoted by the service and that staff understood how people's capacity should be considered. People told us that they could approach the staff and manager if they were unhappy or had ideas to discuss.

We spoke with three people who lived at the home. One of them told us, "This is a good home". We asked people what the staff were like and one of them said, " I really like them", another said, "They are really kind to me".

We spoke to people about the things they liked to do at the home. One of them said, " I love going to college". Another told us that he liked to go in to the town. We saw that each person had an individual weekly activity programme that enabled them to plan the things they liked to do, including going to the pub, cooking and going to the cinema.

We looked at people's care plans and saw that they were based on their individual strengths and needs and their likes and dislikes. They were regularly discussed with people and updated.

We spoke to staff and they all felt well supported in their roles. Some of the staff we spoke to said they had received supervision but that this had not been done as regularly recently. Not all of them had received an annual appraisal.

The home had effective arrangements in place for safeguarding people from abuse and there was a complaints system in place.

Six of the eight people who live in this home went out for a meal on the day we visited. Two people told us they were able to choose how they spent their time and could make choices about the way they lead their lives.

Feedback on surveys sent out by the home and completed by the people who live there, their relatives and other stakeholders was positive. People were clearly supported to live the lifestyle of their choice and to be as independent as possible.

People told us they felt safe and that they would speak to the registered manager or their key worker if they had a problem.

Care records confirmed that people are fully involved and consulted about the care and support that they received. Daily records showed that people participated in a range of activities that they had chosen and enjoyed.

Staff knew the people living at the home well and had a good understanding of their support needs.

The inspection took place on 3 and 4 August 2015 and was unannounced.

Westhope Mews is registered to accommodate up to eight people. It specialises in providing support to people with a learning or physical disability. The accommodation is provided on the ground floor of a purpose built property and there is level access throughout. There is a communal lounge, dining room and activities room. The service shares the use of a minibus with two of the providers other services in the area.

The service had a registered manager. 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 registered manager and staff told us over recent months they had not always operated with the staffing levels the provider had assessed they needed to operate the service. The registered manager explained they had two vacancies which they were in the process of recruiting to but had struggled to fill. They said over this period they had spent more time working on the floor to deliver care than they normally would and less time on their management responsibilities and as a consequence, many of the records we looked at were incomplete or in need of updating. Whilst the registered manager was already aware of the shortfalls we identified at this inspection, they had not formulated an action plan to address them. People, their representatives, and staff were all encouraged to express their views and complete satisfaction surveys. Feedback received showed a high level of satisfaction overall however the results of the surveys had not been analysed to help drive improvement in the service.

Staff told us they would be confident reporting any concerns about people’s safety or welfare to the registered manager or nominated individual. However when incidents that affected people’s safety and welfare had occurred, the local authority safeguarding team had not been informed and incidents had not been analysed to identify any emerging themes or trends in order for them to decide if an investigation was needed.

Risk assessments were not all robust and did not always specify on what basis a risk had been identified and control measures put into place for example restricting access to the kitchen or the use of bed rails. The actions taken to minimise risks were not always the least restrictive. We were told one person lacked the capacity to give their consent to care and treatment and to agree to restrictions that were placed on them for example to be under constant supervision and to having bed rails in place. However a mental capacity assessment had not been completed to assess this and an application to the local authority had not been made for them to authorise the deprivations of liberty this person was subject to until after our inspection.

The provider’s procedures for administering people’s medicines were safe but staff had not always followed them. Some people’s medicines were out of date, staff did not have specific guidance for follow in relation to when as and when needed medicines should be administered and the stock of some medicines did not balance with the stock indicated in medicine records.

Some staff recruitment files were not available to view. Therefore it was not possible to establish how the registered manager had assessed that it was safe for these staff to work at the home or that they had the skills and experience they needed to support the people that lived there.

People were supported to be independent and live the lifestyle of their choice. One member of staff said “People can do what they want.” Another staff member said “We are helping people to do the things they cannot do themselves.” People led active lives and were supported to participate in a range of activities that they enjoyed. People were supported and encouraged to maintain relationships with people that mattered to them and there were no restrictions on visiting.

Staff knew the people well and were aware of their personal preferences, likes and dislikes. One person said “They are gentle with me, they don’t rush me.” Person centred support plans were in place detailing how people wished to be supported, and people were involved in making decisions about their care. However not all aspects of these plans were up to date. Staff told us they kept up to date with changes to people’s care though reading the communication book, people’s daily records and by attending staff handovers and meetings. People were supported with their healthcare needs and staff liaised with their GP and other health care professionals as required. One person said “When I ring the bell they come quickly”.

Staff felt supported and received regular training. They had obtained or were working towards obtaining a nationally recognised qualification in care. They were knowledgeable about their roles and responsibilities and had the skills, knowledge and experience required to support people with their care and support needs.

Feedback about the registered manager and staff was positive. They described an ‘open door’ management approach, where the registered manager was available to discuss suggestions and address problems or concerns. A member of staff said “We are a good team, everyone gets on well”.

We identified four areas where the provider was not meeting the requirements of the law. You can read what action we have told the provider to take at the back of the full version of the report.