Westcliff House

Westcliff House is a residential care home providing personal and nursing care for up to 34 people living with learning disabilities and/or mental health needs. The service is divided into two wings. The Sidborough Wing provides a more traditional care home setting substantially for people with learning disabilities, some of whom are older people who have lived there for many years. The Roborough wing is set up as individual flats for people living with learning disabilities or long-term mental health needs. At the time of our visit there were 25 people living at the service.

The service was registered prior to the implementation of Registering the Right Support, a set of principles and values that underpin best practice for services supporting people living with a learning disability and/or autism. However, the service adheres to these to ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

The service was a large home, bigger than most domestic style properties. It was registered for the support of up to 34 people which is larger than current best practice guidance. However, the size of the service having a negative impact on people was mitigated by the building design fitting into the residential area and the other large domestic homes of a similar size. Staff were discouraged from wearing anything that suggested they were care staff when coming and going with people.

People’s experience of using this service and what we found

Improvements had been made since the previous inspection in December 2018 to how the service supported people to manage risks to their health, safety and welfare. Care plans and risk assessments described risks associated with people’s needs and guided staff about how to support people in a way that mitigate these. Care plans also held more detail about people's abilities and their preferences with how they were supported.

People’s medicines were managed safely.

People told us they enjoyed the food provided and their choice of evening meals had improved since the pervious inspection.

People told us they felt safe living at Westcliff House. The relatives we spoke with also felt the service was safe; they described the staff as “wonderful” and “amazing”. Staff were aware of their responsibilities to protect people and to report concerns should they suspect someone was being abused, mistreated or neglected.

There were enough staff available to support people. They had been safely recruited and received the training they needed for their role. People told they had a good relationship with the staff. One person said, “The staff are lovely and very supportive. They spend time talking with us.”

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff told us people had capacity to make decisions and choices about how they wished to live their lives. Staff respected people’s decisions, even if those decisions were ones that others might think of as not being good decisions. The service worked closely with other care professionals, such the community mental health team, GPs and community nurses, to ensure people received the support they required.

The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent. The registered manager told us people had few goals and ambitions, with people happy to remain stable and well. This was something the service was looking to develop, to encourage people to think about their future and things they would like to achieve.

The registered manager had continued to develop a service's quality assurance system and service improvement plan. They told us how these used it to review the outcomes of their regular safety and quality audits, as well as to record when improvements were required and completed. People and staff told us the service was well managed. There were clear lines of accountability and each member of staff was aware of their role and responsibilities.

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

Rating at last inspection

The service was previously inspected in December 2018 and rated requires improvement. The report was published on 11 January 2019. We found one breach of regulation relating to risk management. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

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

People’s experience of using this service:

People told us they felt safe living at Westcliff House. People had close and respectful relationships with the staff, registered manager and provider. People’s independence and rights to make choices about their care were respected. People were happy with their accommodation and we saw improvements to the décor and furnishings of the building had been made and these were on-going.

Since the previous inspection, the registered manager and provider had worked with the local authority’s quality assurance and improvement team (QAIT) to address the improvements identified at that inspection. These included improvements to care plans and risk assessments, both individual and environmental, as well the systems used to monitor the quality and safety of the home. The home had developed a service improvement plan and while progress had been made, the required improvements had not been fully completed. Some improvements were still required with risk assessments and care planning as well as how the home monitored one person’s behaviour and how they responded to another person’s health condition.

Staff were able to tell us about people’s care needs; however, some people’s care plans and risk assessments did not describe these needs or provide staff with guidance about how to support people while keeping them safe from harm. The registered manager reported further progress had been made on these since the inspection.

Medicines were managed safely. The home sought guidance from health care specialist such as learning disability, epilepsy and diabetes nurses.

People gave mixed views about the quality of the food provided. Some people said they enjoyed the food and it was very good while others said they felt the quality was poor. Some people asked for the evening meal choice to be reviewed. In response, the registered manager had provided each person with a questionnaire to allow them to give their individual views about the food and what meals they would like to see on the menus.

Recruitment practices were safe and staff received the training they required to undertake their role. Staff were supported through regular supervisions, appraisals and meetings. There were sufficient staff employed to meet people’s care needs, but some people indicated they wished to spend more time with staff in leisure and social activities.

We found one breach of the regulations in relation to safe care and treatment. More information is in the detailed findings below.

Rating at last inspection: Requires improvement. Four of the key questions were rated ‘requires improvement’, with the key question of ‘well-led’ rated ‘inadequate’. The last inspection was undertaken in March and April 2018 and the report was published on 25 June 2018.

Why we inspected: This was a planned, scheduled inspection based on the previous rating.

Enforcement: The provider is required to send us an action plan regarding the breach of regulation and how the home is going to achieve a rating of good.

Follow up: This is the third time Westcliff House has been rated requires improvement. We will meet with the provider after an action plan has been sent to us to discuss the improvements they are going to make.

This inspection took place on 28 March and 4 April 2018 and was unannounced. At our last inspection of the service in January 2017 the service had been in breach of three regulations of the Health and Social Care Act 2014. These were in relation to acting in accordance with the Mental Capacity Act, good governance and staff training and support.

On this inspection we found the service had taken action to meet the breach in relation to staff training and support, but remained in breach of regulations relating to the Mental Capacity Act and good governance. The breach for the regulation regarding staff training was however again breached as we found instances of where there had not been sufficient staff on duty to meet people’s needs. In addition we identified new breaches of regulations relating to safe care and treatment, treating people with dignity and respect, safe staff recruitment, safeguarding and person centred care.

We found the overall rating for the service is requires improvement for the second time.

The service has 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 was not present for the first day of the inspection, but was for the second.

The service was not developed and operated in line with the values that underpin the “Registering the right support” and other best practice guidance as it preceded this guidance being in place. Values identified in the guidance include choice, promotion of independence and inclusion, so that people with learning disabilities using the service can live as ordinary life as any citizen. We have asked the registered manager and provider to consider how their service can be further aligned with these values.

The service was not always well led. We identified a number of new concerns on this inspection that had not been identified in the service’s own quality assurance systems. The service was not always following their own policies and procedures in practice and had not regularly taken actions to assess the quality and safety of the services provided, including regular audits.

People were not always being kept safe because the provider had not ensured systems in place were effectively protecting people from abuse. Policies and procedures were in place to identify and respond to allegations of abuse and staff had received training in how to identify concerns. However, we found that staff and management had acquired a tolerance of behaviour from the people living in the home towards others that was potentially abusive.

Risks to people were not always reduced because staff did not understand people’s health and welfare needs and what actions they needed to take to keep individual people safe. Records were not always in place to support people with risks associated with specific health conditions. Risk assessments did not always contain detailed guidance for staff on how to reduce or manage risks related to people’s behaviours.

Risks associated with the environment had not always been assessed or mitigated. We found two windows above ground level did not have window restrictors fitted, water temperatures at taps and baths were delivered at temperatures higher than recommended and radiators were not covered. This meant people were not being protected from hot surfaces or from the risk of scalds. Not all areas of the buildings were clean or well maintained.

People’s rights were not being protected because the provider had not acted in accordance with the requirements of the Mental Capacity Act 2005 (MCA). Mental capacity assessments completed by staff were general statements and not decision specific. Decisions made for people had not been recorded in line with the best interests decision making process. People were being deprived of their liberty without the necessary legal authorisation to do so.

People’s care plans did not always reflect a person centred approach, or follow the principles of positive behavioural support when supporting people living with a learning disability. Plans did not focus on identifying people’s goals or strengths or how to meet any aspirations they may have, including increasing independence. Some needs assessments or plans relating to physical conditions were not completed in sufficient detail for staff to understand what actions to take for that person.

People told us they did not know about their care plans or had not seen them. We made a recommendation to the provider about seeking guidance about involving people further in their care planning.

People told us they felt safe and well supported by the home and the staff. We saw staff supported people with patience and a caring attitude. Staff knew people and their wishes well. Staff spoke about people they supported with affection and compassion. They told us “We strive to give our best to everyone.” However, not all comments from people living at the service were positive and we saw occasions where people’s privacy or dignity was not always respected. One person told us they did not feel they were always treated with respect with regard to managing a continence issue. We saw several people did not appear well groomed.

The service had supported people to raise concerns about treatment they had experienced. However, people told us they were not all sure of what they would do to raise a complaint. Some people told us “I don’t know how to make a complaint”, “I don’t bother” or “I would not know what to do but I would be afraid to complain as I am afraid of what they would do”. One person told us they had made a complaint but nothing had improved. We made a recommendation about managing complaints.

Systems were in place to ensure staff were recruited safely but these were not always being operated robustly. One staff file did not contain a full employment history. There were not always enough staff on duty to support people to carry out the activities they wanted to do.

Staff were receiving regular supervision, and received training to help them carry out their work. Staff told us they felt supported by the management.

People received their medicines safely. Protocols were in place for the administration of ‘as required’ medicines however, there was not a robust system in place for the auditing of medicines. We made a recommendation the provider reviews their medicines administration auditing processes.

We received variable feedback about the food and meals served. Some people told us they really enjoyed the meals and had a good variety. Other people told us there was little choice or variety. We have recommended the service consult with people about their satisfaction of the meals served. People were supported to have access to health care services when needed.

People were supported to follow their own activities and interests. Some of the people living in the Roborough wing were largely independent and ‘very active in the local community’. However, some people living in the Sidborough wing were much more dependent on activities arranged by the service. When we asked how they spent their time we received mixed views. One person said, “We haven’t got anything to do. I used to like puzzles. I don’t do them anymore.”

Westcliff House is comprised of two period buildings spread over five floors some of which could be accessed via a stair lift. We found some of the accommodation was looking tired and in need of refurbishment. The registered provider told us they were carrying out improvements on the environment this year.

Some people living at the service were elderly, and some also had sensory impairments. No assessment had been carried out to assess how people with sensory impairments such as sight loss, could have their environment improved to increase their independence or maximise their vision. We made a recommendation about improving the environment to meet the needs of people.

People told us they felt the service was well led and were positive about their support. People were encouraged to give their views about how well the service was working and what could be improved through regular questionnaires. Staff told us they enjoyed working at the service, worked well as a team and understood their roles.

We found 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.

We carried out this inspection on 10 January 2017. The service was last inspected in August 2014 and was found to be meeting the regulations.

There was a registered manager in post who was responsible for the day-to-day running of the 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 and associated regulations about how the service is run.

Each person was allocated a key worker who knew and understood their care and support needs. However, care records did not reflect the knowledge staff had about people’s needs. Care plans lacked detail about personal history, daily routines and personal preferences. Where people could display behaviour that might be challenging to others there was no information in their care plan to provide guidance for staff. When staff worked with people, they were not so familiar with, information about people’s care needs was mostly communicated to them verbally. This meant there was a risk that staff would not know how to provide the right care for people, if key staff were not available, because care records had insufficient detail.

Staff demonstrated they knew the type of decisions each individual person could make and when they might need support to make decisions. However, where people lacked capacity, there was no documentary evidence that people’s capacity to make particular decisions had been assessed or records of best interest decisions made. Staff were unaware of the Mental Capacity Act (MCA) 2005 and did not understand how the legislation related to the way they provided care and support for people.

Staff were not consistently supervised, supported and trained to carry out their roles. Staff training was not being updated to ensure staff had the skills and knowledge to provide effective care to people. The registered manager and deputy manager were visible in the service and regularly worked alongside staff to provide care and support for people. However, formal individual supervision with staff had not taken place for some time, with some newer members of staff not having had any formal supervision. This meant staff did not have the opportunity to discuss their development and identify any training or support needs they might have.

People told us they felt safe living at Westcliff House and with the staff who supported them. Comments from people included, “I am very happy here, yes it's nice here”, “Yes, I do feel safe.” A relative told us, “[Person’s name] is very happy living here.”

On the day of our inspection there was a relaxed and friendly atmosphere at the service. People were encouraged and felt confident to make decisions about their daily living. We observed people had a good relationship with staff and each other. There was plenty of friendly and respectful chatter between people and with staff. The staff team had developed kind and supportive relationships with people using the service. People commented about staff, “I am happy with the care, everyone here is really nice” and “Really really lovely people here and very caring, nothing seems too much trouble.”

People were supported to access the local community and take part in a range of activities of their choice. People went out shopping and to local attractions and some had paid and volunteering work. Activities were provided for people to take part in within the service and these included puzzles, board games and art therapy. People were supported by staff to manage their finances so they could purchase personal items and pay for outings.

There were sufficient numbers of suitably qualified staff on duty and staffing levels were adjusted to meet people’s changing needs and wishes. Staff completed a thorough recruitment process to ensure they had the appropriate skills and knowledge. Staff knew how to recognise and report the signs of abuse.

Staff supported people to maintain good health, have access to healthcare services and receive on-going healthcare support. People had access to an annual health screening to maintain their health.

People were supported to eat and drink enough and to maintain a balanced diet within which they were involved in meal planning. Menu planning was done in a way which combined healthy eating with the choices people made about their food. People told us they were happy with the meals provided.

People and their families were given information about how to complain. People and their families were involved in the running of the service and were regularly asked for their views through continuing conversations with staff and surveys.

The management provided strong leadership and led by example. There was a positive culture within the staff team and with an emphasis on providing a good service for people. Staff told us they felt supported by the management commenting, “It’s a nice environment to work in”, “Yes it's well run, I have nothing but respect for the manager, he's brilliant” and “Best place I have ever worked, it’s down to the manager. If there’s a problem he is on it.”

The registered manager worked alongside staff, regularly providing care for people and this enabled him to check if people were happy and safe living at Westcliff House. People spoke well of the registered manager and clearly felt comfortable approaching him. One person told us, “The manager is great, he's amazing.” The owner was also visible in the service and regularly checked if people were happy and safe living at Westcliff House.

We identified three breaches of the regulations. You can see what action we have told the provider to take at the back of the full version of the report.

Below is a summary of what we found. The summary describes what people using the service and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We saw that a risk assessment had been completed in relation to concerns over one person's clothing choice. This was because the person's clothing choices, whilst respecting their individuality, had not protected their dignity or ensured the public were protected from seeing them unsuitably clothed. This had resulted in appropriate action being taken to keep people safe.

Is the service caring?

We saw that care had been taken to ensure people were able to lead the lifestyles they wished.

Is the service effective?

We saw action had been taken to protect people living at the home and respect other people in the community.

Is the service responsive?

Appropriate action had been taken in response to the challenges posed in allowing people to make lifestyle choices whist ensuring they were kept safe and their dignity was maintained.

During this visit we found that people were offered choices and were treated with dignity and respect. We saw that there was a range of activities and outings available to people.

We found that care plans had been updated and gave care workers information on people's needs and how they liked their needs to be met. Care workers were aware of this information and told us they ensured people's needs were met as the individual wanted.

Care workers were aware of the procedures to be followed if they suspected abuse had occurred.

People were protected from the risks associated with care workers who may be unsuitable to work with vulnerable people. This was because the provider had effective recruitment procedures in place.

The provider had systems in place to assess and monitor the quality of the service provided.

We looked at four care and support plans. We found that the person's assessment of need had not been recently updated. Risk assessments were not clearly up to date so it was not always possible to see what the risks were and how to minimise them.

Domestic staff followed a cleaning schedule and the home was clean and tidy. Cleaning equipment and products were colour coded and clearly labelled. There was an infection control policy which staff had read and signed to state it had been understood.

Staff felt well supported and had opportunities for further training. Staff we spoke with told us 'I love my job' and 'I really enjoy working here'

Complaints were recorded and investigated. When necessary the provider assisted people who lived in Westcliff House to raise concerns and make a complaint.