12 April 2023
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.
The inspection was completed by 1 inspector and an Expert by Experience on the first day of inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. On the second day of inspection an Inspector, a medicines inspector and a nurse specialist nurse advisors were present at the service.
Service and service type
Marple Dale Hall – The New Windsor 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. Marple Dale Hall – The New Windsor is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
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. This included any information of concern and notifications the service is required to submit regarding any significant events happening at the service. We sought feedback from the local authority, professionals who work with the service and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. 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 reviewed staffing levels and walked around the building to ensure it was clean and a safe place for people to live. We observed how staff supported people and provided care.
We spoke with 8 people who use the service, 4 relatives and 12 members of staff, including the manager, deputy manager, senior care workers, care workers, auxiliary staff and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
We reviewed a range of records including 10 people's care records. We looked at 4 staff files in relation to recruitment, training, and support. We reviewed 9 medicine administration records and looked at medicines related documentation. We observed medicines administration, checked storage, and spoke with 3 staff in relation to the management of medicines. A variety of records relating to the management of the service, including policies and procedures were examined.
12 April 2023
About the service
Marple Dale Hall – The New Windsor is a care home providing personal and nursing care for 57 people at the time of the inspection. The service can support up to 63 people. The service provides care to people living with dementia, physical disabilities and/or an acquired brain injury.
People’s experience of using this service and what we found
People felt safe and were happy with how they were supported. People’s needs and risks were assessed, and equipment used to support people to remain independent. Where things had gone wrong, work was completed to ensure lessons were learnt. Staff were recruited following safer recruitment methods and there were enough staff to meet people’s needs. The service was clean and tidy. Medicines were managed safely, however we recommend reviewing how people are supported to have their medicines crushed safely, and processes for recording the application of topical medicines such as creams.
People’s needs were assessed, and choices and preferences supported and respected by staff. Staff completed a variety of training and felt well supported in their role. We have made a recommendation about training in line with requirements. People were supported to access various healthcare input as needed and staff followed advice given. People were supported to eat and drink well, and mealtime experiences were pleasant. Feedback about the quality of food was mixed and ongoing work was being completed to improve this. 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.
A wide variety of systems were in place to ensure the quality and safety of the service and, where issues were identified, action was taken to address any shortfalls. People, relatives, and staff spoke positively about the management team and felt able to share feedback and raise concerns. The management team used a variety of processes to obtain feedback from people, families, and staff. The registered manager and staff were committed to ensuring positive experiences of care and people were supported to have improved outcomes.
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 requires improvement (published 13 July 2021) and we found breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.
At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
This inspection was prompted by a review of the information we held about this service.
We carried out an unannounced focused inspection of this service on 8 June 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve person-centred care, safe care and treatment and good governance at the service. We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.
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 requires improvement to 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 Marple Dale Hall – The New Windsor on our website at www.cqc.org.uk.
We have made a recommendation that the provider ensures all mandatory training in line with the requirements of regulation and best practice are available and being completed by staff as needed and the provider reviews how people are supported to have their medicines crushed safely, and processes for recording the application of topical medicines such as creams.
We will continue to monitor information we receive about the service, which will help inform when we next inspect.