Richmond Village Letcombe Regis

Updated 11 July 2023

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 Health and Social Care Act 2008.

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

This inspection was carried out by 1 inspector, 1 Specialist Nurse Advisor and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Richmond Village Letcombe Regis is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Richmond Village Letcombe Regis is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

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 who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 8 people who used the service and spoke to 4 relatives about their experience of the care provided. We contacted 18 members of staff including the registered manager, regional support manager, nurses, and care staff. We observed the interaction between people and staff.

We reviewed a range of records. This included 11 people’s care records and medication records. We looked at 3 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 11 July 2023

About the service

Richmond Village Letcombe Regis is a retirement village, the care home forms part of the main building. The care home accommodates up to 53 people in two units. The service supports older people and people living with dementia. At the time of our inspection there were 34 people using the service.

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

Systems and processes were not always effective in assessing, monitoring, and improving the quality of the service. Concerns found on inspection had not been identified or rectified.

Risks to people had not always been fully assessed or mitigating strategies completed. People were at increased risk of abuse as injuries did not always have a cause or an investigation completed.

There were not always sufficient staff deployed to meet people’s needs in a timely manner.

People and relatives had not all been asked to feedback on the service. People and relatives had not always seen or been part of their care plan and staff did not always have time to read people’s updated care plans.

People were supported by staff who had been safely recruited and who had received sufficient training.

People were supported safely with their medicines. Staff administered medicines as prescribed and had all the necessary information regarding people’s medicines.

Staff felt supported within their roles and felt they worked well as a team.

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.

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 20 February 2021)

Why we inspected

We received concerns in relation to use of equipment, management oversight and falls. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this 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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Richmond Village Letcombe Regis on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to risk management and management oversight 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 from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.