Westgate Court

Not everyone using the service received a regulated activity. The Care Quality Commission (CQC) only inspects the service being received by people provided with 'personal care'; help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. At the time of our inspection 25 people were being supported with personal care.

The service was predominately for people who were living with acquired brain injuries; however, some people were also supported with learning disability or autism. Due to this, we inspected the care provision against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed autistic people and people with a learning disability respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. We found the provider was not always meeting the ‘Right support, right care, right culture’ guidance.

We inspected the service due to the length of time since the last inspection. During this inspection we found the provider needed to make improvements.

People did not always have appropriate risk assessments in place. Risk assessments that were in place lacked detail and guidance for staff. Care plans which are used to provide information around the individual support a person requires lacked person-centred detail and there was not always a care plan in place to guide staff around specific health concerns.

People received their medicines when needed, however this was not always in line with the prescription. The provider had not identified that protocols were missing for people who required medication on a ‘when required’ bases, people who required topical creams did not have documentation in place to evidence appropriate application.

People had capacity assessments and best interest decision records in place for certain aspects of their care. However, the provider had failed to ensure capacity assessments and consent had been obtained for people who required monitoring equipment and for the use of lap belts on wheelchairs, which could be considered a form of restraint. Therefore, we could not be assured the service was working in line with the principles of the Mental Capacity Act (2005).

Staff supported people with kindness and passion for their roles and supervision was provided by team leaders who were onsite daily. However, team leaders lacked the knowledge and experience needed to be able to ensure care was meeting best practice guidance and that regulations had been met. The registered manager was available to staff via the telephone but had limited availability within the services. This has had a negative impact on the effectiveness of the governance within the service.

The provider had processes in place to help review and monitor the service, however not all areas of the peoples care records were audited to ensure safety and quality had been checked. The audits which were taking place lacked detail and failed to highlight the concerns raised during the inspection.

People had not been affected by the shortfalls identified; however, people were potentially at risk of poor care due to the concerns found during the inspection. We found 4 breaches of regulation. These are in relation to concerns surrounding the service’s governance, risk management and lack of person-centred care. We found breaches of regulation in relation to medication management and consent to care. We have asked the provider for an action plan in response to the concerns found at this assessment.