About the service:

• Westgate House is a care home that provides personal and nursing care for up to 80 people.

• At the time of the inspection it was providing a service to 79 people.

• For more details, please see the full report which is on the CQC website at www.cqc.org.uk

People’s experience of using this service:

• People and their relatives could not be reassured that their complaints were investigated in a timely manner.

• The provider did not always follow suitable recruitment procedures to ensure people’s needs were met safely.

• The provider lacked effective quality assurance systems to ensure the quality and safety of the service.

• People were protected against avoidable harm, abuse, neglect and discrimination. The care they received was safe.

• People's risks were assessed and strategies put in place to reduce the risks.

• People's likes, preferences and dislikes were assessed and care packages met people's desired expectations.

• People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

• People and their relatives provided positive feedback about the care, staff and management. They said the service was caring, timely, effective and well managed.

• People's care was person-centred. The care was designed to ensure people's independence was encouraged and maintained.

• People and their relatives were involved in the care planning and review of their care.

Rating at last inspection:

• Requires improvement (report published 15 May 2018). This is the third consecutive time the service has been rated Requires Improvement.

Why we inspected:

• All services rated "requires improvement" are re-inspected within one year of our prior inspection.

• This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.

Enforcement:

• We identified two breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 around the recruitment of fit and proper persons, and complaints. Please see the ‘action we have told the provide to take’ section towards the end of the report.

Follow up:

• The service is required to provide an action plan to us because there were two breaches of the regulations.

• We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

• We made one recommendation in our inspection report, which we will follow up at our next inspection.

This inspection took place on 4 and 5 April 2018 and was unannounced. The service was last inspected in April 2017. At the last inspection we made 11 recommendations for the service. These were regarding the administration of covert medicines, the administration of topical medicines, supporting people who present with behaviour which may cause harm to themselves or others, recruitment practice, supervision of staff, engaging staff in organisational change, understanding and application of the MCA, menu planning, end of life care, supporting people who identify as lesbian, gay, bisexual and transgender, and activities. We found the service had made improvements across the service however we found recruitment procedures were still not robust.

Westgate House 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.

Westgate house provides nursing home care to up to 80 people. At the time of our inspection 79 people were living in the home. The home is divided across three floors. One floor provides specialist dementia nursing care, another provides general nursing care and a third provides nursing care to people with complex nursing needs including tracheostomy care.

There was a registered manager at this service. 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.

Recruitment and selection procedures were not always carried out in line with the provider’s policy and procedure and may have placed people using the service at risk of harm by unsafe recruitment and selection practices.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we asked the provider to take at the back of the full version of this report.

Staff told us they received regular supervision and appraisals. However supervision and appraisal records did not always contain sufficient detail to demonstrate what had been discussed. We have made a recommendation about supervision.

The experiences of people who lived at the home were positive. People told us they felt safe living at the home, staff were kind and compassionate and the care they received was good. Staff had a good understanding of their responsibility with regard to safeguarding adults.

People’s needs were assessed and their preferences identified as much as possible across all aspects of their care. Risks were identified and plans in place to monitor and reduce risks. People had access to relevant health professionals when they needed them. Medicines were stored and administered safely.

Staff undertook training and received one to one supervision to help support them to provide effective care. The registered manager and staff we spoke with had a good understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). MCA and DoLS is law protecting people who are unable to make decisions for themselves or whom the state has decided their liberty needs to be deprived in their own best interests.

People told us they liked the food provided and we saw people were able to choose what they ate and drank.

People’s needs were assessed and met in a personalised manner. Care plans were in place which included information about how to meet a person’s individual and assessed needs. People’s cultural and religious needs were respected when planning and delivering care. Discussions with staff members showed that they respected people’s sexual orientation so that lesbian, gay, bisexual, and transgender people could feel accepted and welcomed

This inspection took place on 24, 25, and 26 April 2017 and was unannounced. The service was last inspected in August 2016 when it was found to be in breach of Regulations 11, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection the service was no longer in breach of any regulations.

Westgate house provides nursing home care to up to 80 people. At the time of our inspection 78 people were living in the home. The home is divided across three floors. One floor provides specialist dementia nursing care, another provides general nursing care and a third provides nursing care to people with complex nursing needs including tracheotomy care.

The provider had recently appointed a new home manager who was in the process of becoming registered. 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.

There was variety in the quality and detail of care plans and risk assessments. Although some contained a high level of detail and personalisation, others lacked the detail required to support people in a personalised way and mitigate risks they faced. Risk assessments and care plans in place for people who presented with behaviour which could harm themselves or others did not tell staff how to support people to stay safe. Care plans and risk assessments were reviewed monthly although they were not always updated to reflect changes in people’s circumstances. Some people told us they were involved in the care planning process, but others did not feel they had been involved.

People were supported to take medicines and this was managed in a safe way. However, improvements were required with regard to the storage of refrigerated medicines, covert medicines and the administration of topical creams. People’s health needs, contact with and advice from health professionals were clearly recorded in people’s files.

Staff were knowledgeable about the different types of abuse people living in the home might be vulnerable to and were confident in the action they would take if they suspected people were being abused. Records showed appropriate investigation and response to incidents.

The provider had invested in new furniture and fittings in the home and it was well presented, clean and a welcoming environment. A room that had previously been under-used as a meeting room had been converted into a café room with tea, coffee and cakes available for people and their visitors to access freely.

The home had improved their records regarding deprivation of liberty safeguards and where people had legally appointed decision makers. However, records of consent to care were not clear and staff understanding of the Mental Capacity Act (2005) was limited.

There were enough staff deployed in the service to meet people’s needs. Checks were carried out to ensure that staff did not have criminal histories that would make them unsuitable to work in a care setting. Recruitment records were inconsistent regarding how interviews were conducted and references were not always collected in line with the provider’s policy. Staff received training in order to give them the knowledge required to perform their roles. Staff supervision and appraisal were not taking place in line with the provider’s policy and records of supervisions showed these were task focussed and did not give staff opportunities for development or learning. Staff who worked during the day attended regular meetings about the service, but night staff had not had any staff meetings since our last inspection.

Staff facilitated activities with enthusiasm. However, the purpose and structure of activities was unclear and potentially confusing to people living with dementia.

This inspection took place on 8, 10 and 17 August 2016. The first day of the inspection was unannounced.

At the last inspection in June 2015 the service was in breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as people were at risk due to poor infection control measures at the service. At this inspection we found these issues had been addressed and the service was meeting the requirements of Regulation 15.

Westgate house provides accommodation and nursing care to older people living with dementia and younger people with nursing needs. The service is registered with the Care Quality Commission to provide care for up to 80 people, 79 people were living in the home at the time of our inspection.

The home had 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.

People were not always protected from the risk of avoidable harm as risk assessments lacked details required to ensure they were supported safely.

The systems for ensuring the safe management of medicines were not used consistently across the service. The guidelines in place for people who had been prescribed medicines on an ‘as needed’ basis were insufficient and people did not have individual medicines support plans or risk assessments.

People told us, and records confirmed, the service did not always have enough staff on duty to ensure people’s needs were met. Activities staff were used to cover gaps in the rota and this meant people did not always have access to activities. People and their relatives said that activities provided did not meet the needs of people living with dementia, or those who could not leave their bedrooms. We have made a recommendation about activities.

People told us they felt safe, and staff were knowledgeable about safeguarding adults from harm. However, the service was not always raising safeguarding concerns as required.

Staff were recruited in a safe way and received the support and training they required to perform their roles.

Records of consent did not demonstrate that the service was seeking consent in line with legislation and guidance.

People and their relatives gave us mixed feedback about the food provided by the home. The home was working with people, their relatives and the provider’s hospitality team to improve the range of food provided to ensure it met people’s preferences.

People were supported to access healthcare services as required.

People’s care plans were not consistently personalised and it was not clearly recorded that people and their relatives had been involved in writing and reviewing plans of care. Relatives told us that changes were not always made when requested.

The home had a robust policy for complaints and records showed complaints were responded to in line with the policy.

People told us they thought staff were caring, and they were treated with dignity and respect. People were supported to maintain their personal relationships and practice their religions where they wished to do so.

People and their relatives gave us mixed feedback about the openness and availability of the registered manager. Some people found her easily accessible but other people said she was not available to them.

The provider completed regular and robust audits of the quality of care provided. However, the actions in place to address issues identified were not effective, as the same issues were identified repeatedly and during our inspection.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

This inspection took place on 30 June 2015 and was unannounced. At the previous inspection of the service in May 2014 we found breaches of legal requirements. This was because risk assessments for people were not completed properly, the use of bed rails for some people was unsafe and people were not always able to consent to their care and treatment. After that inspection the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. At this inspection we found improvement had been made and that they now met the previous legal beaches.

Westgate House provides accommodation and care to older persons with dementia care needs and those in need of nursing care. The service is registered with the Care Quality Commission to provide care for up to 80 adults, 78 people were using the service at the time of our inspection. The service had 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.

We found that the service did not have effective systems in place to manage infection control and parts of the service were dirty. You can see what action we have asked the provider to take at the end of this report. People told us that staff did not always treat people in a caring manner. Complaints raised informally where not always managed appropriately.

Appropriate arrangements were in place for safeguarding people. Staff had undertaken training in this area and where knowledgeable about their responsibility for reporting any allegations of abuse. Enough staff worked at the service to meet people’s needs and checks were carried out on prospective staff. Risk assessments were in place about how to support people in a safe manner. Medicines were stored, recorded and administered safely.

Staff undertook training and received supervision to support them to carry out their roles effectively. People were supported to consent to care and the service operated in line with the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. People were supported to eat and drink sufficient amounts and had choice over what they ate. People were supported to access healthcare professionals.

The service carried out assessments of people’s needs before they moved in to ascertain if it was able to meet those needs. Care plans were developed and subject to regular review.

The service had a clear management structure in place and people and staff told us they found senior staff to be approachable and helpful. The service had various quality assurance and monitoring systems in place. Some of these included seeking the views of people that used the service.

We carried out this inspection under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by the CQC which looks at the overall quality of the service.

This was an unannounced inspection. At our previous inspection of Westgate House in November and December 2013 we found the provider was not meeting the requirements of the law in relation to the care and welfare of people, dealing with complaints and record keeping. Following that inspection the provider sent us an action plan to tell us the improvements they were going to make. During this inspection we looked to see if these improvements had been made.

Westgate House is a nursing home for up to 80 older people. At the time of our inspection 78 people were living at the service.

People were generally positive about the care provided at Westgate House. However, we found that people’s safety was compromised in some areas. This was in relation to the usage of slings and bed rails. We saw positive interactions between staff and people using the service, but staff were busy during the lunchtime period and were not always able to respond to people when they needed assistance during this period.

Staff were not always following the Mental Capacity Act 2005 for people who lacked capacity to make a decision. For example, on one floor of the building we were told that staff did not do mental capacity assessments for specific decisions despite some people needing their capacity to be formally considered.

We found people’s health care needs were assessed, however we saw a number of risk assessments which had been completed incorrectly.

Staff were recruited safely and given appropriate training.

The service had a complaints procedure and we saw records to indicate that complaints were being dealt with in line with the procedure. Relatives we spoke with knew how to make a complaint and were confident that their feedback was acted on.

Staff at Westgate House carried out regular audits. Where any improvement or action was needed this was dealt with. However, the monthly auditing of care records did not identify the issues we found.

The service sought the feedback of relatives and people living at the service. Residents’ meetings were held at least every three months and further actions arising from these meetings were recorded and dealt with appropriately.

We carried out this inspection under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by the CQC which looks at the overall quality of the service.

This was an unannounced inspection. At our previous inspection of Westgate House in November and December 2013 we found the provider was not meeting the requirements of the law in relation to the care and welfare of people, dealing with complaints and record keeping. Following that inspection the provider sent us an action plan to tell us the improvements they were going to make. During this inspection we looked to see if these improvements had been made.

People told us that they were happy with the home. One person told us “they treat me alright” and another said “it’s the same as it was the last time you visited”.

One person told us that they liked to sit where they could see visitors come and go and listen to their favourite music during the day, they said “I like it here, they are all good to me”

Many of the people that use the service at Westgate House have dementia and high dependency health care needs therefore not everyone was able to tell us about their experiences. To help us to understand the experiences of people we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they have positive experiences.

We spent much of our time observing the daily life for people who live in the various units at different times of the day. From using the SOFI we saw that not everyone’s experience of the service they received were positive. We saw that for most of our observation time the only engagement people living in the service had with staff was when a care task such as moving the person or assisting them with feeding was being undertaken. These engagements were not always a positive experience for people. We observed care that on occasion outpaced the people that lived there; we saw that staff did not always interact positively with people; and we saw care delivered to people who were not always engaged with the process.

People’s opinions of care ranged from, “Could be a lot worse” to “Wonderful, could not wish for more”.

Some people said they had no complaints and felt they were treated well by the staff that did their best to meet their needs.

Some people said they thought the home was “nice and clean”, “The food is good, we get a cooked breakfast when we want it, which sets you up for the day”.

Relatives said they had confidence in the staff and if they needed to raise any concerns they felt able to do so directly with the staff or the manager.

We were told, “The staff are very welcoming, it is like a home from home”. “We always get offered a cup of tea and piece of cake when we visit”.

Two people we spoke to told us they felt they had needed to insist on action being taken by staff, to ensure the safety and wellbeing of their relatives following specific incidents.

We undertook two visits to the home as part of this inspection. One visit was conducted at 3.45am due to concerns raised by relatives regarding the quality and safety of care provided.

We found people’s individual needs had been assessed before moving into the home. Care and treatment was planned and delivered in a way that was intended to ensure their safety and welfare. Staff had a good understanding of people’s needs and people who used the service told us that they were given choices and treated with respect. Care files evidenced that a range of health care professionals were involved in people's care and treatment. Although care plans showed a holistic approach to care, daily records reflected a task based approach and we found little evidence that people’s social, emotional and psychological needs were being fulfilled.

Appropriate equipment had been provided for those people who needed it. Equipment that we saw was clean and well maintained but not always stored appropriately.

The home has in place a satisfactory complaints procedure. However when we looked at the complaints records we found the information recorded was not always consistent with the information received by us from people who said they had made a complaint.

Records were not always accessible, accurate and up to date. We were concerned to find some health care records had been completed ahead of the task.