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Inspection Summary


Overall summary & rating

Good

Updated 4 January 2019

Freegrove Care Home can accommodate up to 17 people. The accommodation is arranged over two floors with a lift available to access the upper floor. People in care homes receive accommodation and their care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided and both were looked at during this inspection. Freegrove Care Home is owned and managed by Mrs C Duffin who, throughout this report, is referred to as the provider. This inspection took place on the 3 and 4 December 2018 and there were 14 people using the service.

The service is not required to have a registered manager. This is because the provider is registered with the Care Quality Commission as an individual and is providing the day to day management of the service. 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.

At our last inspection we rated the service as overall good. At this inspection, whilst we found some areas where improvements could be made, our findings continued to support an overall rating of good.

The areas for improvement were:

Notifications of incidents and accidents that had occurred had not always been sent to CQQ as required.

Some of the records relating to how the service was managed contained missing information or were not accurately completed.

Whilst incidents and accidents were investigated, these sometimes lacked robustness and learning from these was not yet being consistently applied.

The provider’s governance and quality assurance systems were not yet being fully effective at monitoring the quality and safety of the service.

Other areas were overall good.

There were times when staff could have been more effectively deployed. The provider is reviewing staffing arrangements to address this. Recruitment was safe.

Overall medicines were managed safely and people received their medicines as prescribed.

Staff followed infection control guidance and the home was visibly clean.

People had individual assessments of risk associated with their care and support and the staff knew how to support people in a way that minimised these risks.

Health and safety checks were carried out to ensure the safety of the building and equipment within it.

Staff had received training in safeguarding adults, and had a good understanding of the signs of abuse and neglect.

Staff understood their responsibility to raise concerns and report on incidents and accidents.

People received effective care from staff that had the right skills and knowledge to carry out their role. Whilst staff felt supported in their roles. The frequency with which they were receiving supervision had declined.

The provider demonstrated a clear commitment to protecting people’s rights. Where people's liberty or freedoms were at risk of being restricted, the proper authorisations were in place or had been applied for.

People told us they enjoyed the food provided and staff were informed about whether people were nutritionally at risk.

Staff worked effectively with a number of health care professionals to ensure that people received co-ordinated care, treatment and support.

People were treated with dignity and respect and staff were kind and caring in their interactions with people.

People and their relatives were involved in making decisions and planning care.

People received care that was centred on them as an individual. Staff recognised and responded to changes in people’s health care needs.

People were supported to follow their interests and take part in social activities.

People and relatives were confident they could raise concerns or complaints and these would be dealt with.

People and

Inspection areas

Safe

Good

Updated 4 January 2019

The service remained safe.

Effective

Good

Updated 4 January 2019

The service remained effective.

Caring

Good

Updated 4 January 2019

The service remained caring.

Responsive

Good

Updated 4 January 2019

The service remained responsive.

Well-led

Requires improvement

Updated 4 January 2019

The well led domain continued to be rated as requires improvement.

Notifications of incidents and accidents that had occurred had not always been sent to CQQ as required.

Whilst incidents and accidents were investigated, these sometimes-lacked robustness and learning from these was not yet being consistently applied.

The provider’s governance and quality assurance systems were not yet being fully effective at monitoring the quality and safety of the service.

People and their relatives expressed confidence in the provider and their ability to manage the home well. Everyone spoke positively about the friendly and homely culture within the home.