Background to this inspection
Updated
15 March 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 Care Act 2014.
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 three inspectors.
Service and service type
Charnwood Oaks Nursing is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager who was in the process of registering with the Care Quality Commission. This means that they and the provider would be legally responsible for how the service is run and for the quality and safety of the care provided.
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. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.
During the inspection
We spoke with two people who used the service about their experience of the care provided. We spoke with nine members of staff including the manager, regional manager, deputy manager, senior care worker, care workers and clinical staff. We observed the care people received in communal areas of the service.
We reviewed a range of records. This included seven people’s care records and multiple medication records. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records.
Updated
15 March 2022
About the service
Charnwood Oaks Nursing Home is a residential care home providing personal and nursing care to 81older people aged 65 and over at the time of the inspection. The service can support up to 84 people.
The service accommodates people across four separate units, each of which has separate adapted facilities.
People’s experience of using this service and what we found
People were not consistently kept safe. The relevant risk assessments to promote safe care and minimize the risk of catching and spreading infections were not in place. This meant staff did not have information on how to safely provide support to people.
The managers did not always have robust oversight to ensure all areas of safe care and infection prevention and control were monitored.
We have made a recommendation about oversight of safe care and risk assessments.
Staffing had improved at the service. The managers had taken action to address most concerns we found at our last inspection. At this inspection, we found further action was required to continue to improve the service.
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 15 September 2021) and there were two breaches of regulation. We served a warning notice and the provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made/sustained, and the provider was still in breach of regulations. This service has been rated requires improvement for the last three consecutive inspections.
Why we inspected
This was a planned inspection as part of CQC’s response to the COVID-19 pandemic we are looking at how services manage infection control and visiting arrangements. During the inspection we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led to check whether the Warning Notice we previously served in relation to Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met / on a specific concern we had about governance and safe care and treatment. The overall rating for the service has not changed following this inspection and remains requires improvement.
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 have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Charnwood Oaks Nursing Home on our website at www.cqc.org.uk.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified continued breaches in relation to safe care at this inspection.
Follow up
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.