Visitation of Our Lady Residential Care Home

We found the following examples of good practice.

• People living at the home were supported to have visitors and appropriate checks were carried out to comply with current guidance.

• We saw the home was clean and a cleaning rota was in place for the Sisters. There were PPE stations around the home and outside the bedrooms with clinical waste bins in the bathrooms. There were posters displayed with guidance on the correct use of PPE. Windows in communal areas were opened regularly to encourage good ventilation.

• The registered manager had a clear process for COVID-19 testing of both people living at the home and the Sisters.

• There was a process in place to manage any outbreaks which included people being cared for in their bedroom if they tested positive and guidance on using enhanced PPE.

• Support was provided for people to keep in contact with their family and friends.

• Risk assessments had been carried out to identify any possible issues and how to mitigate possible risks.

• Everyone working at the home had completed infection control training which included COVID-19.

Visitation of Our Lady Residential Care Home offers personal care for up to nine older people and is run by a Roman Catholic Polish Community. At the time of our inspection, five people were living at the service. The staff lived at the home and were a community of nuns from Poland.

There was a registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People received their medicines safely. Staff received training in the administration of medicines and there were regular medicines audits.

People and staff told us they felt safe and there were systems and processes in place to protect people from the risk of harm.

There were enough staff on duty to care for people because staff lived at the service and were always available.

There were appropriate procedures in place for the safeguarding of people at risk of abuse and these were being followed.

There were systems in place for the management of incidents and accidents and appropriate action was taken to reduce the risk of reoccurrence.

People were supported by staff who were trained, supervised and appraised. The registered manager attended provider forums in order to keep abreast of developments within the social care sector.

People’s nutritional and healthcare needs had been assessed and were met.

The provider acted in accordance with the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS). People’s capacity was assessed and where they could, they had consented to their care and support. Where people lacked capacity, we saw that best interests decisions were made. Processes had been followed to ensure that, where needed, people were deprived of their liberty lawfully.

People and their relatives told us that the staff and registered manager were caring and communicated effectively with them, responded to their needs promptly and treated them with kindness and respect. The staff team knew people well and delivered care that made people feel valued. The whole staff team promoted person centred values as the basis of the service and ensured these were followed at all times.

The whole staff team understood the importance of ensuring people’s emotional, spiritual and cultural needs were met as well as their physical needs.

Care plans were in place and people had their needs assessed and reviewed regularly. Care plans contained information that reflected the needs and wishes of the individual.

There was a complaints procedure in place and people and their relatives knew how to make a complaint. They felt confident that their concerns would be addressed.

People and relatives were given questionnaires to gain their feedback on the quality of the care provided.

People, relatives and professionals we spoke with thought the home was well-led. The staff told us they felt supported by the registered manager and there was a family atmosphere and a culture of openness and transparency within the service.

The provider and registered manager undertook regular safety audits and action was taken when issues were identified.

Visitation of Our Lady Residential Care Home offers personal care for up to nine older people. At the time of our inspection, five people were living at the service. The service is a care home for people predominantly from the Roman Catholic Polish Community. The staff lived at the home and were a community of nuns from Poland.

There was a registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider had taken action to address some of the concerns identified at the inspection of 20 and 23 October 2015 and had put systems in place for the safe storage of received medicines. However, staff did not always follow the procedure for the recording and safe administration of medicines. This meant that people were still at risk of not receiving their medicines safely.

The registered manager did not undertake medicines audits and had not received training in the administration of medicines since 2014, therefore they failed to identify and rectify medicines errors.

Staff had received training identified by the provider as mandatory, however, some courses were not refreshed regularly.

The provider had made improvements and had acted in accordance with the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). People’s capacity was assessed and they consented to their care and support. Processes had been followed to ensure a person had been deprived of their liberty lawfully.

The provider had made improvements to the supervision of staff and regular one to one meetings were taking place. Staff appraisals were scheduled for the end of the year.

The risks to people’s safety were identified and managed appropriately and people were cared for safely.

There was a daily health and safety audit which indicated that all areas of the home were checked for safety and any areas requiring maintenance were identified.

All staff were nuns who were appointed by the Order’s Sister General in Poland, and had been working at the service for many years. All staff had a Disclosure and Barring Service (DBS) check carried out.

There were enough staff on duty to keep people safe and meet their needs in a timely manner.

There were appropriate procedures in place for the safeguarding of vulnerable people and these were being followed.

Staff treated people with kindness and dignity and took into account their human rights and diverse needs. People and relatives told us that people were safe and happy at the service.

People and staff lived together as a community. People were cared for in a relaxed and unrushed atmosphere. People were complimentary about the staff and indicated that the religious ethos of the home contributed to the good care and support they received.

People’s nutritional and healthcare needs had been assessed and were met.

Assessments were carried out before support began to ensure the service could provide appropriate care. Care plans were developed from the assessments and reviewed regularly.

There was a complaints procedure in place and people and their relatives knew how to make a complaint. They felt confident that their concerns would be addressed. Relatives were sent questionnaires to gain their feedback about the quality of the care provided.

Daily events and activities were recorded in a diary for all people rather than in their individual care records.

People, relatives and professionals we spoke with thought the home was well-led. The staff told us they felt supported by the registered manager and there was a family atmosphere and a culture of openness and transparency within the service.

We have made recommendations in relation of the management of incidents and accidents and training.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which related to safe care and treatment and quality assurance. You can see what actions we told the provider to take at the back of the full version of this report.

We spoke with two people who use the service who said they were comfortable at the home and the staff were kind and supportive. We toured the home and found the home was clean and well maintained. Care was being provided in a homely and comfortable environment. Staff were receiving annual mandatory training to ensure they had the skills and knowledge to carry out their work effectively. People or/and their relatives were asked for their views on the home and people had completed questionnaires in 2012 giving their views on the home.