Archived: West Lane

Updated 31 July 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 3 December 2014 and was unannounced.

The inspection team consisted of two inspectors and one specialist advisor. The specialist advisor had a nursing background.

We looked at three peoples care plans. We spoke with two people that used the service. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spent time observing care and speaking with the registered manager and staff. We spoke with one visiting professional and prior to the inspection we asked for feedback from the City of Bradford Adult Protection Unit. We looked at care plan documentation as well as documentation relating to the management of the service such as training records, policies and procedures

On this occasion we did not ask the provider to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. Before the inspection, we reviewed all the information held about the provider.

Updated 31 July 2015

On the 03 December 2014 we inspected West Lane. This was an unannounced inspection.

West Lane provides accommodation for persons requiring nursing and personal care to a maximum of 12 people who are living with learning disabilities. All the accommodation is in single rooms and the service is located in the residential area of Thornton, close to Bradford city centre.

There was 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.

At the last inspection in January 2014, we found a breach of regulation 13 (management of medicines) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We inspected the home again on 3 December 2014 and we checked whether improvements had been made.

We found some improvements had been made to the medicine management system. Medicines were administered in a safe way. However, we saw protocols and guidance were not always followed. Some documentation for administration lacked key information. Not all medicines were stored correctly in line with best practice.

We saw the provider had a safeguarding and whistleblowing policy in place. We saw the notice boards had posters and leaflets about safeguarding and who to contact. We spoke with staff about safeguarding. Staff could describe warning signs of abuse and what action they would take.

We looked at people’s risk assessments which demonstrated how people were protected from identified risks and that measures had been put into place to reduce or remove further risk.

We saw that accidents and incidents were recorded and analysed for trends. This showed us that accidents and incidents were monitored effectively.

Staffing levels in the home were sufficient to meet people’s needs. During the inspection we saw people were not left without assistance for any significant periods of time. We found some staff needed refresher training to ensure their training was up to date. Staff understood their roles and responsibilities, as well as the values of the home. Staff had effective support and supervision.

Care plans had been completed and reviewed on a regular basis. Plans had been written in a person centred way. People’s plans of care included their choice, likes and dislikes and personal preferences. Staff completed daily records for people to record activities and people’s wellbeing.

We observed during lunch time in the home. People were served food that was suitable for their diet. Those that needed support with eating received it. People had the weight recorded on a regular basis. This record would prompt staff if someone had a significant weight loss to take action.

Staff understood the needs of people and we saw that care was provided with kindness and compassion. People spoke positively about the home and the care they received. Staff took time to talk with people or support with activities such as reading or drawing.

The Care Quality Commission (CQC) monitors the operation of the DoLS (Deprivation of Liberty Safeguards) which applies to care homes. Where people were deprived of their liberty in order to keep them safe the provider had applied for authorisation. This meant they were acting lawfully and were meeting the requirements of the DoLS.

A complaints system was in place and staff we spoke with had confidence any concerns and complaints would be appropriately dealt with. We saw action had been taken to resolve one current complaint. This showed us the complaints policy was effective and staff followed the correct procedure.

The registered manager ensured a robust programme of quality assurance was in place. We saw regular quality audits fed information into an action plan to help improve the service. The action plan was then worked through to make the necessary changes.