Archived: Westbrook House

Updated 21 August 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by two inspectors.

Service and service type

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

The service should have 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. No registered manager had been in post since April 2020.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We spoke with two people who used the service about their experience of the care provided. We spoke with the nominated individual, the nominated individual is responsible for supervising the management of the service on behalf of the provider, and nine members of staff. This included, the acting covering manager, the deputy manager, the service support manager, the community service development manager, and six care staff. Not everyone using the service could provide verbal feedback on the care provided, therefore we carried out observations of people’s care to help us understand people’s experiences.

We reviewed a range of records. This included fives people’s care records and four people’s medication records. A variety of records relating to the management of the service, including audits and records relating to health and safety were reviewed.

Updated 21 August 2021

About the service

Westbrook House is a residential care home providing personal care to people with a learning disability and/or autistic people. The service can support up to seven people. At the time of the inspection there were five people living in the home. Westbrook House is a terraced house set over four floors.

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

People living in the service had been exposed to risk of harm. Risks relating to numerous areas including the environment had been poorly assessed and responded to. Safeguarding systems were ineffective and exposed people to risk of abuse. Incidents were not always reported and when incidents occurred staff did not take effective actions to mitigate risks. People were exposed to an increased risk of infection, this included in relation to COVID-19. Staffing was poorly managed, and this impacted on the ability of staff, including managers, to carry out their roles. Medicines were not being safely managed.

People were not being supported by staff who had the correct skills and training. Best practice guidance and legislation was not being applied. The environment had been poorly maintained and was dirty. People were living in dirty bedrooms with mould and damp. Staff were not supporting people in the service to eat healthily and in some cases people’s individual needs around their diet were not met. Staff were not proactive in managing or responding to people’s healthcare needs.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The dirty poorly maintained environment was not respectful and did not promote their dignity. People were not supported by staff who paid attention to their needs and ensured these were met. Staff did not always treat people with respect. People’s rights were not fully protected and as a result their property and finances were not always treated respectfully. Staff were not effectively utilising the systems in place to ensure people were fully involved in their care.

The support provided had not adequately met people’s needs or been provided in a timely manner. A lack of person-centred planning meant people’s needs were not considered and met, this was across a wide range of areas including social contact and recreational activities. Staff were not utilising communication systems to ensure people’s communication needs were met.

There was a lack of leadership and management in the service. There had been no registered manager in post since April 2020. Staff spoke about poor communication and support which hampered their ability to meet people’s needs. Governance systems were ineffective and where issues had been identified action to drive improvement had not taken place. The incident reporting and monitoring system was ineffective, and incidents had not been reported where required including to CQC.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. The model of care being followed did not maximise people’s choice, control and independence. The care was not person-centred and did not promote people’s dignity and human rights. There was a lack of person-centred culture and values within the service. These concerns had contributed to people’s individual needs not being met and being placed at risk of harm. The issues identified during the inspection were discussed with the provider. The provider told us they had recognised and identified widespread failings in the service and the poorly maintained environment prior to our inspection. They told us given the extent and nature of the concerns they had identified that the best course of action would be to close the service. At the time of our inspection the provider was working with the local authority to identify alternative placements for people so the service could be closed as soon as reasonably possible.

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 this service was good (published 07 March 2019)

Why we inspected

The inspection was prompted in part due to concerns received about the management of the service, governance and oversight, safe care and improper treatment of service users, and environmental concerns. A decision was made for us to carry out a comprehensive inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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.

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to person-centred care, dignity and respect, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment, meeting nutritional and hydration needs, premises and equipment, staffing, good governance, notification of incidents, and there being no registered manager.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.