Archived: West End Village

Updated 12 October 2021

The Inspection

This was a targeted inspection to check whether the provider had met the requirements of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 on a specific concern risks to people using the service were not being managed effectively.

Inspection team:

The inspection team consisted of one inspector.

Service and service type:

West End Village provide personal care to people living in their own homes in the community.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection:

We gave 24 hours’ notice of the inspection site visit because we wanted to be sure the management team was in the office.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. This included details about incidents the provider must notify us about. We contacted the local authority and the local clinical commissioning group who commission services from the provider. We assessed the information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection, we spoke with the Head of Services and two staff members.

We reviewed a range of records about people's care and how the service was managed. This included looking at four people's care records.

After the inspection

We continued to seek clarification from the provider with regards staff training.

Updated 12 October 2021

About the service

West End Village is a domiciliary care service and extra care housing service providing personal care to 30 people aged 55 and over at the time of the inspection.

People using the service lived both in a large gated community in Stoke-on-Trent and also lived in ordinary houses and flats across Stoke-on-Trent. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

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

People were not always supported to transfer by the number of staff required to meet their needs, placing people and staff at risk of harm. Staff did not always complete Medicine Administration Records (MARs) correctly which meant we could not be assured that medicines were administered safely and as prescribed.

Systems in place to allocate staff failed to ensure sufficient staff were assigned to meet people’s needs safely. Audit systems in place were not always effective in checking the quality of the service. The culture of the service was not positive and did not promote good outcomes for people.

Staff did not consistently deliver effective care in line with people’s care plans. People were not always supported by staff who were caring and empathetic towards them.

Accidents and incidents were recorded and action was taken when needed to reduce the risk of reoccurrence. Staff knew how to prevent and control infection and regular competency checks were undertaken.

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. People were supported by staff who were sufficiently trained to meet people’s needs and their competencies were checked regularly. People were supported to access healthcare professionals when needed.

People were supported to express their views and were encouraged to make decisions about their care. People were supported by staff who respected their dignity and promoted their independence.

People’s preferences were documented in care plans and staff knew people well. People’s communication and sensory needs were considered when planning and providing care. A complaints policy was in place and this was followed.

Staff feedback was obtained via social media groups and through questionnaires so the service could be improved. The management team were proactive in improving care where needed and changes were implemented where needed.

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

Rating at last inspection

The last rating for the service under the previous provider was Good, published on 10 February 2017.

Why we inspected

The inspection was prompted in part due to concerns received about infection control. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective, Caring, Responsive and Well-Led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

The provider has taken immediate action to mitigate the risks but these new systems have not been embedded for long enough for us to determine if they are effective.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified breaches in relation to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Safe care and treatment and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.