This inspection took place on 24, 25 and 26 April 2018. Day one of the inspection was unannounced. This is the first rated inspection of West Farm Care Centre with the provider Miss Lucy Craig.

West Farm Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

West Farm Care Centre can accommodate 50 people in one adapted building across two floors. At the time of the inspection 48 people were resident. The first floor, known as the Shore unit, is for people living with a dementia, although some people living with a dementia also resided on the ground floor.

The service did not have a registered manager. The current manager had been in post since December 2017 and had not made an application to register with the Commission. The provider had notified us that the previous registered manager had left, however, they had not submitted an application to cancel their registration.

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.

During this inspection we found five breaches of regulations we inspected against.

An electronic care planning system was used. Care records contained generic information that was pre-populated by the system. In some cases, the information was not accurate, nor was it specific to the person. Care records were not detailed and did not provide staff with accurate and up to date information on people’s needs.

Risks were not always assessed or included within people’s care records. Specific information and guidance from healthcare professionals was not always used to update care plans and risk assessments.

Consent to care and treatment was not always sought in line with the Mental Capacity Act 2005 (MCA).

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; however, care documentation in the service did not support this practice.

Some incidents, including those staff found challenging, had not been investigated or analysed for themes or triggers for the behaviour. This meant care plans were not in place to support staff to manage the behaviour and minimise risks.

Safeguarding incidents had not always been reported to the local authority safeguarding team or notified to the Commission.

Quality assurance systems had not been effectively implemented to assess, monitor and improve the quality of the service provided to people.

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

Care staff knew people well and had developed dignified, respectful and compassionate relationships with people. People were complimentary about the care and support they received.

Staffing levels were appropriate to people’s needs and robust recruitment procedures were in place. Staff said they felt supported and had attended the training needed to make sure they could meet people’s needs.

Positive relationships had been developed with visiting care professionals.

Activities were currently being managed by the care staff and we saw people enjoyed socialising and engaging with each other.

A refurbishment plan was in place to develop the Shore unit so it was more dementia friendly. People had been involved in the decision making and plans were in place to minimise any disruption to people whilst the work was completed.

Meal times were a pleasant experience and people were offered a choice of freshly made meals using fresh ingredients. Staff were vigilant in offering people drinks and snacks in between meals.

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