St Cyril's Neurological Care and Rehabilitation Service

Updated 9 December 2022

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 consisted of 2 inspectors, a specialist nurse adviser and an expert by experience who undertook telephone calls to relatives. 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

St Cyril’s neurological care and rehabilitation service 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. St Cyril’s neurological care and rehabilitation service 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 and professionals 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 2 service users. We spoke with 7 relatives by telephone about their experience of the care provided. We spoke with the nominated individual, deputy manager, a manager from one of the provider’s other services, 2 nurses, 4 support workers, a speech and language therapist and a physiotherapist. We looked at 5 care plans that included risk assessments and a number of medication records. We looked at 5 recruitment files, training records and a variety of records relating to the management of the service.

Updated 9 December 2022

About the service

St Cyril's Neurological Care and Rehabilitation Service provides accommodation, personal and nursing care within one building separated into distinct wings. They support up to 26 people who require specialist rehabilitation and therapy as a result of neurological injury including acquired and traumatic brain injury. At the time of the inspection 20 people were living at the service.

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

Risks to people were not always effectively managed. We found some people’s pressure area care required improvement. Required documentation was not always in place.

Medication systems and audits had failed to identify that ‘as required’ medicines protocols were not in place.

Fire drills had not been completed to ensure the safe evacuation of people in the event of an emergency. Concerns were identified in relation to one area of the building in regards to safe evacuation.

Systems and processes in place did not provide effective oversight of the service and had failed to identify a number of concerns identified during the inspection.

Staff treated people with kindness and treated them with respect and dignity. Relatives told us that staff were caring, and some staff knew their loved ones well.

People were supported by a multi-disciplinary team to engage in a rehabilitation programme that was individual to them.

Staff were aware of the latest government guidance in relation to infection prevention and control and had received training in this area.

There were enough safely recruited staff to meet the needs of the people supported. Staff were trained and competent in the use of moving and handling equipment. Staff told us they felt well supported by the management team.

The provider demonstrated a commitment to continually improve and develop the service.

The provider had policies and procedures in place to support and guide staff. There was a complaints procedure in place that people and their relatives were aware of. Relatives told us they felt confident to raise any concerns and complaints they had.

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 and update

The last rating for this service was good (published 29 July 2021).

Why we inspected

This inspection was prompted by a review of the information we held about this service. 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. This is based on the findings at 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 St Cyril's Neurological Care and Rehabilitation Service on our website at www.cqc.org.uk.

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 monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report. During and following the inspection, the provider took action to mitigate the risks identified.

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.