Old Sarum Manor

Updated 21 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

This inspection was carried out by one inspector.

Service and service type

Old Sarum Manor 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. Old Sarum Manor 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 not a registered manager in post. An interim manager had applied to become registered prior to our inspection.

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 which included information of concern. We sought feedback from the local authority who work with the service. The provider was not asked to complete 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 6 people and 1 relative about their experiences of care received. We spoke with 7 members of staff, assistant manager, interim manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. The providers quality director was also present on day 1 of the inspection.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed care and support records for 9 people, multiple medicines records, incident and accident records, falls analysis, medicines management records, 4 staff files for recruitment and health monitoring records.

After the inspection

Following our site visit we contacted Healthwatch for any information they had about the service. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We also spoke with a further 5 members of staff, 4 relatives and we contacted 4 healthcare professionals by email for their feedback about the service. We received feedback from 1 healthcare professional.

We continued to validate evidence found and reviewed quality monitoring records, policies and procedures, quality surveys, meeting minutes and service improvement plan.

Updated 21 December 2022

About the service

Old Sarum Manor is a service providing accommodation and personal care for up to 66 people. The service provides support to older people over 65 years, people living with dementia, sensory impairment, physical disabilities and younger adults under 65 years. At the time of our inspection there were 66 people using the service.

Accommodation was provided over three floors accessed by stairs and a lift. People had their own rooms with en-suite facilities. There were also communal areas on each floor, including a cinema, café, hair salon, lounges and dining areas. People could access a secure garden from the ground floor.

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

Incidents and accidents had not consistently been reported to management so appropriate action could be taken in response. In addition, it was not always clear what actions were taken to prevent reoccurrence. This had been identified by the provider prior to our inspection and a new process was in place. This needed time to embed into practice. The provider also took responsive action during the inspection to review and improve systems.

Due to the shortfall in incident management there was an impact on duty of candour response letters. The provider took action to review this during the inspection and update responses sent to relevant people. The provider’s quality systems had not identified some of the incidents we found. We have made a recommendation about this.

Medicines had been managed safely. We did find some ‘as required’ protocols not in place. This had been identified by the provider prior to our inspection, action was being taken to put them in place. Staff had medicines training and checks on their competence regularly.

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.

The service was clean, and schedules were in place to make sure all areas of the home were checked. People and relatives told us they were very happy with the standards of cleanliness seen throughout the home. People had regular visits from friends and family, there were no visiting restrictions.

Staff wore personal protective equipment appropriately and had received training on good infection prevention and control procedures. Staff had been recruited safely and there were enough staff to meet people’s needs. People and relatives told us people felt safe at the service and they all appreciated the caring approach of the staff.

There was not a registered manager in post, however, an interim manager had applied to be registered prior to our inspection. People, relatives and staff told us the management of the service was inclusive, responsive and that management were approachable and visible. Systems were in place to give people and relatives opportunities to share their views and there were regular ‘residents meetings’.

Staff also had opportunities to meet regularly with management and they all told us they felt listened to and valued.

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 2 November 2021).

Why we inspected

We received concerns in relation to medicines, senior staff interactions with people and people struggling to eat. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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.

We did not find any evidence to substantiate the concerns received. We have however, found the provider needs to make improvements in other areas. Please see the key question safe section of this full report.

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 remained good based on the findings of this inspection.

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

Recommendations

We have made one recommendation about the provider’s quality monitoring systems in the key question well-led.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.