Rendlesham Care Centre

Updated 31 July 2021

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 Care Act 2014.

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 was undertaken by one inspector.

Service and service type

Rendlesham Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service did not have a manager registered with the Care Quality Commission. Registered managers and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. There was a manager in post who had submitted an application for registered manager to CQC.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

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 all of this information to plan our inspection.

During the inspection

We visited the service on the 28 and 30 June 2021. We spoke with six people who used the service about their experience of the care provided. We spoke with the regional manager and manager and briefly with five members of staff including care staff and laundry staff. We observed part of the medicines round, mealtimes and interactions between staff and people using the service. We also observed a flash meeting, which included the manager and heads of departments.

We reviewed a range of records. This included four people’s care records and multiple medicines records. We looked at two staff files in relation to recruitment.

We asked for records to be sent to us to review them remotely. A variety of records relating to the management of the service, including policies and procedures, audits, incidents and accidents, staff rotas and staff training records were reviewed. We also spoke with three people’s relatives and six staff members including the deputy manager, the chef, housekeeping, nursing, senior and administration staff, on the telephone.

We fed back our findings of the inspection on 15 July 2021 to the manager, regional manager, operations director and the director of compliance, governance and quality.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We reviewed additional information sent to us, including training records and records of updates sent to people’s relatives by the manager.

Updated 31 July 2021

About the service

Rendlesham Care Centre is a residential care home providing personal and nursing care to 33 people at the time of the inspection. Some people using the service were living with dementia. The service can support up to 60 people in one adapted building. There are three units in the service, one on the first floor and two on the ground floor. At the time of our inspection one of the units on the ground floor was closed for refurbishment.

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

The provider had an action plan in place and was in the process of improving the service. This was not yet fully implemented and embedded in practice. The local authority was not placing new people into the service until improvements had been made. The provider and management team were working with the local authority to evidence how improvements were being implemented. There were systems in place to learn lessons and reduce future risks.

A new manager had been employed in the service in June 2021, we received positive feedback about the manager and improvements they were making. There had been no registered manager in post since June 2020, the provider had made attempts to address this in the period between that manager leaving and the new manager being appointed.

There were systems in place to reduce the risks to people living in the service, this included risks associated with their daily living and from abuse. Medicines were managed safely, and auditing systems supported the management team to identify shortfalls and reduce them.

Staffing levels were calculated to meet people’s needs and ongoing recruitment, which was done safely, was undertaken. Infection control processes in place reduced the risks to people living in the service. Staff were wearing personal protective equipment (PPE) appropriately and a programme of COVID-19 testing was done. The provider was following government guidance relating to people having visitors.

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 3 March 2018).

We undertook a targeted inspection in January 2021, following an incident where a person was harmed, which is subject to investigation. We did not examine the circumstances of the incident at this inspection but checked how people were being supported to reduce the risks of pressure ulcers developing. CQC have introduced targeted inspections to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Why we inspected

We received concerns in relation to safe care, recording and governance. The local authority had ceased to place people in the service until improvements are made. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. The service was working on an improvement plan to address these concerns. We have found evidence that the provider needs to make improvement, because their improvement plan had not yet been fully implemented and embedded in practice. Please see the Well-led section of this report.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

There was an ongoing investigation regarding a specific incident. This inspection did not examine the circumstances of the incident.

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.

The overall rating for the service has not changed and remains good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Rendlesham Care Centre on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.