Updated 22 December 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
The inspection team comprised of 1 inspector 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
Ecclesholme 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. Ecclesholme is a care home without 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
Inspection activity started on 19 October 2023 and ended on 24 November 2023. We visited the location’s service on 24 October and 7 November 2023.The first day was unannounced, which meant the provider did not know we would be visiting on that day. The second day was announced.
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 completed a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us 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 8 people who used the service, the relatives of 8 people and 2 visitors. We also spoke with 13 members of staff including the registered manager, deputy manager, team leaders, care workers and ancillary staff, plus a visiting community health professional.
During the inspection visit we looked at the management of people’s medicines and reviewed 4 care plans. We also looked at areas of health and safety, staff recruitment and audit and management systems. Additional electronic evidence, including a selection of policies, procedures and audits, sent to us securely were reviewed remotely.