Archived: Sedra Nursing Home

Updated 20 May 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 21 April 2016 and was unannounced.

The inspection was carried out by two inspectors, a pharmacy inspector and an expert-by-experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. The expert on this inspection had experience of residential and nursing services for older people including those living with dementia.

Before the inspection, we reviewed the information we held about the service, including notifications we had received from the provider and the findings of previous inspections. Notifications are for certain changes, events and incidents affecting the service or the people who use it that providers are required to notify us about.

During the inspection, we spent some time observing care and support being delivered to help us understand people’s experiences of using the service. We also looked at records, including the care plans for four people who used the service, three staff records and records relating to the management of the service. We spoke with eight people who used the service, 11 staff, including the registered manager, five care staff, the activities coordinator, a domestic worker and two healthcare students who were on a placement at the home. We also spoke with two relatives who were visiting people at the time of our inspection.

Following our visit, we spoke with four healthcare professionals and a social care professional who were regularly involved in the care of people using the service to gather their views about the service.

Updated 20 May 2016

The inspection took place on 21 April 2016 and was unannounced. The service was last inspected on 29 April 2014 and at the time was meeting all the regulations we looked at.

There was a registered manager at the service 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.

Sedra Nursing Home offers accommodation and personal care for 19 older people, 12 of whom were living with dementia. There were 13 single rooms and three shared rooms. The registered manager told us that all rooms will eventually be single rooms, which will reduce capacity to 16. There were 18 people in residence at the time of our inspection.

Staff did not always follow the procedure for recording, storing and safe administration of medicines. This meant that people were at risk of not receiving their medicines safely.

The service employed one activities coordinator and we saw there were organised activities on the day of our inspection. However the delivery of those was disorganised and did not take into account people’s individual choices and needs.

The care plans we looked at were signed by people or their relatives where possible, and we saw evidence of best interest assessments where people lacked the capacity to make decisions about their care and support.

People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. Care plans were reviewed and updated monthly and included detailed instructions for staff to follow to ensure people’s needs were met. Care plans contained information about people’s daily routines and preferences.

The provider had processes in place for the recording and investigation of incidents and accidents. Risks to people’s safety were identified and managed appropriately.

There were enough staff on duty to meet people’s needs in a timely manner.

People felt safe when staff were providing support. Staff had received training and demonstrated a good knowledge of safeguarding adults.

People’s capacity to make decisions about their care and treatment had been assessed. Processes had been followed to ensure that, when necessary, people were deprived of their liberty lawfully.

Staff received regular supervision and an annual appraisal, and told us they felt supported by their manager. There were regular staff meetings and meetings with people and their relatives.

Staff had received training identified by the provider as mandatory to ensure they were providing appropriate and effective care for people using the service.

Recruitment records were thorough and complete and the provider had ensured that staff had a Disclosure and Barring Service (DBS) check prior to starting work.

There was a complaints process in place and people told us they knew who to complain to if they had a problem. Relatives were sent questionnaires to gain their feedback on the quality of the care provided.

People told us they felt safe at the home and trusted the staff. They told us staff treated them with dignity and respect when providing care. Relatives and professionals we spoke with confirmed this.

We saw people being cared for in a calm and patient manner.

People gave positive feedback about the food and we observed people being offered choice at the point of service. People had nutritional assessments in place. People had access to healthcare professionals as they needed, and the visits were recorded in their care plans.

The provider had a number of systems in place to monitor the quality of the service and put action plans in place where concerns were identified.

People, relatives and professionals we spoke with thought the home was well-led and the staff and management team were approachable and worked well as a team.

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