Background to this inspection
Updated
17 August 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 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.
Inspection team
The inspection was carried out by one inspector.
Service and service type
Noss Mayo 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. Noss Mayo is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
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. We sought feedback from the local authority who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with three people who used the service about their experience of the care provided. We spoke with four members of staff including the registered manager, senior care worker, care worker and the cook.
We reviewed a range of records. This included three people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. 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
17 August 2022
About the service
Noss Mayo is a residential care home providing accommodation and personal care to 13 people aged 65 and over at the time of the inspection. The service can support up to 14 people.
People’s experience of using this service and what we found
Quality assurances systems had continued to be developed and implemented. However, we found further work was required as some of these still did not ensure effective oversight of the care home.
Care plans detailed how to support the person to ensure their assessed needs could be met. We found some clear plans required further work to ensure they contained current up to date information to meet people’s needs.
Safe recruitment systems and processes were in place. Training was provided for staff to ensure they could carry out their role safely and effectively, any gaps had been identified and addressed by the registered manager.
People’s nutritional needs were met and detailed in their care plans. Mealtime experiences were positive and people who required a modified diet were well supported.
People told us they felt safe. People and staff provided positive feedback on the management of the service.
Staff had received safeguarding training and were able to demonstrate their understanding and responsibilities to reduce the risk of harm to people.
Staff showed a caring approach to how they supported people. Empathy and compassion were demonstrated for people at the end of their lives.
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.
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 inspection for this service (published 06 January 2022) concerns were raised regarding risk management, medicines management, governance and leadership. We found the provider was in breach of regulation 12 and 17 and a warning notice was issued. This was a focussed inspection and we did not review all key questions. The provider completed an action plan to show what they would do and by when to improve.
The last rating for this service was requires improvement (published 06 January 2022). The service remains rated requires improvement.
Why we inspected
We undertook this inspection to check whether the provider had met the breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014 and that the Warning Notice we previously served had been met. The provider met the warning notice, however, remains in breach of regulation 17. The overall rating for the service has not changed following this comprehensive 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 Noss Mayo Residential 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 will take further action if needed.
We have identified a breach in relation to governance at this inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.