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Inspection Summary


Overall summary & rating

Good

Updated 6 June 2018

This inspection was carried out on 15 May 2018 and was unannounced.

At the previous two inspections on 31 January 2017 and 17 October 2017 the service was rated as ‘Requires Improvement’ because the provider was found not to be meeting the required standards. At the last inspection in October 2017 we found that people had not consistently received person centred care that took account of their health, care and social needs and were not involved in planning or reviewing their care. We also found that people had not always received safe care and treatment and that the provider’s governance systems were not effective because they had not identified the shortfalls we had found.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve all the key questions Safe, Effective, Caring, Responsive and Well-led to at least good. The action plan was submitted 21 November 2017 and stated that actions would be completed by 01 March 2018 in order to ensure the provider was meeting identified breaches of regulations 9, 12 and 17 of the Health and Social care Act (Regulated Activities) Regulations 2014.

Providence Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. On the day of this inspection 45 people were living at Providence Court in one purpose built building.

The service had a manager who was registered with the Care Quality Commission (CQC). 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. However, at the time of this inspection the registered manager was absent from the home with no clear date for their return. In the interim a deputy manager from a sister home was undertaking management responsibilities with support from the regional manager and the quality team.

We found significant improvements from our previous inspection in October 2017. However, these need more time to be embedded into the everyday culture of the home. People were not aware of who was managing the home in the registered manager’s absence. Staff gave us mixed views about how effectively communication worked within the home. Staff felt supported by the current management team. The manager had developed an information sharing tool that was used to cascade learning from accidents and incidents through the staff team. There were quality assurance systems in place which included audits undertaken by the home’s management team and representatives of the provider. The management team worked closely with external organisations for the benefit of the people who used the service.

People told us that they felt safe living at Providence Court. Staff demonstrated an understanding about reporting incidents of concern. Potential risks to people's health, well-being or safety had been identified and reviewed regularly to take account of people's changing needs. We observed safe moving and handling practice. A successful recruitment campaign had resulted in more permanently recruited staff available to provide people with consistent care and support. People were supported by sufficient numbers of safely recruited staff. People’s medicines were managed safely. People had personal evacuation plans in place for in the event of an emergency such as fire and we saw that regular safety checks were completed. The home was clean and fresh and infection control practices were appropriate.

The service worked in accordance with the Mental Capacity Act 2005 (MCA).People told us they enjoyed the food provided for them. Assessments had bee

Inspection areas

Safe

Good

Updated 6 June 2018

The service was safe.

People told us that they felt safe.

Staff members demonstrated an understanding about reporting incidents of concern.

The home was clean and fresh and infection control practices were appropriate.

Potential risks to people's health, well-being or safety had been identified and reviewed regularly to take account of people's changing needs and circumstances.

We observed safe moving and handling practice.

A successful recruitment campaign meant that there were more permanently recruited staff available to provide people with consistent care and support.

People were supported by staff who had been through a robust recruitment process.

People’s medicines were managed safely.

People had personal evacuation plans in place for in the event of an emergency such as fire and we saw that regular safety checks were completed.

The manager had introduced a system to cascade shared learning from incidents around the staff team.

Effective

Good

Updated 6 June 2018

The service was effective.

People were supported to access healthcare support as needed.

The service worked in accordance with the Mental Capacity Act 2005 (MCA).

People told us they enjoyed the food provided for them. Assessments had been undertaken to identify when people may be at risk from poor nutrition or hydration and appropriate action was taken accordingly.

People told us that they received care from staff who were skilled and knowledgeable.

The staff members we spoke with said they were totally confident to approach the current management team for additional support at any time.

Caring

Good

Updated 6 June 2018

The service was caring.

Staff took action to help people if they were experiencing difficulty.

The management team had taken steps to ensure people, or their relatives where appropriate were involved in planning their care.

People told us that staff were kind and caring.

Staff and management interacted with people in a warm and caring manner.

People were able to make choices about activities of day to day living.

People's care records were stored in a lockable cupboard in communal areas on each unit in order to maintain the dignity and confidentiality of people who used the service.

Visitors to the home were welcomed and greeted brightly by the staff at reception.

Responsive

Good

Updated 6 June 2018

The service was responsive.

People had received the support they needed to be comfortable and smart.

People's care plans were sufficiently detailed to be able to guide staff to provide their individual care needs.

A variety of activities were being developed to help provide stimulation and engage people.

People and their relatives knew how to make a complaint. The provider had a robust overview of complaints made to the service and these were reviewed as part of the regional manager’s routine checks.

Well-led

Requires improvement

Updated 6 June 2018

The service was not always well-led.

We found significant improvements from our previous inspection in October 2017. However, these need more time to be embedded into the everyday culture of the home.

The registered manager was absent from the home with no clear date for their return. In the interim the home was being managed by a deputy manager from another of the provider’s services with additional support from the regional manager and the provider’s quality team.

People were not aware of who was managing the home in the registered manager’s absence.

Staff gave us mixed views about how effectively communication worked within the home.

Staff felt supported by the current management team.

The manager had developed an information sharing tool that was used to cascade learning from accidents and incidents through the staff team.

There were quality assurance systems in place which included audits undertaken by the home’s management team and representatives of the provider.

The management team worked closely with external organisations for the benefit of the people who used the service.