Archived: Culworth House Care Home with Nursing

Updated 10 January 2017

We undertook an unannounced focussed inspection of Culworth House Care Home with Nursing on 7 December 2016. This inspection was completed in response to concerns about the safety of the premises and the environment. As a result we undertook a focused inspection to look into those concerns. This report only covers our findings in relation to those topics.

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 was completed by two inspectors. Before the inspection we reviewed the information we held about the service, including statutory notifications that the provider had sent us. A statutory notification is information about important events which the provider is required to send us by law. We also contacted health and social care commissioners who place and monitor the care of people living in the home.

During our inspection we spoke with ten people who lived at the home, two members of care staff, one member of domestic staff, the maintenance manager, the deputy manager, the temporary acting manager, the area manager and the provider.

Updated 10 January 2017

This unannounced inspection took place on 11May 2016.

Culworth House is registered to provide accommodation for persons who require nursing or personal care support for up to 35 people. On the day of the inspection 24 people were living in the home.

There was a registered manager in post 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 about how the service is run.

Staff had good relationships with the people who lived in the home. There were enough staff to ensure that people received the individual care and support that they required. Appropriate staff recruitment processes were in place; however there were occasions where some staff commenced working in the home, before all necessary checks had been concluded and some of these staff were not consistently supervised in line with their individual risk assessment. There were a range of induction and training programs in place; however training records available in the home were out of date and this made it difficult for the registered manager to assess staff compliance with training. They were taking steps to address the gaps in staff training.

Staff engaged with people in a positive way and people felt safe in the home. Staff understood the need to protect people from harm and abuse and knew what action they should take if they had any concerns. Care records contained individual risk assessments and risk management plans to protect people from identified risks and help to keep them safe. They provided information to staff about action to be taken to minimise any risks whilst allowing people to be as independent as possible.

Care plans were written in a person centred approach and detailed how people wished to be supported and where possible people were involved in making decisions about their care. People were actively involved in decisions about their care and support needs. There were formal systems in place to assess people’s capacity for decision making under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). People were able to choose where they spent their time and what they did. However there was a need to increase the level of stimulation and activities available to people and a staff member had been recruited with the aim of focusing on this aspects of peoples care and support.

People were supported to take their medicines as prescribed. Records showed that medicines were obtained, stored, administered and disposed of safely. People were supported to maintain good health and had access to healthcare services when needed.

Staff were aware of the importance of managing complaints promptly and in line with the provider’s policy. Staff and people were confident that issues would be addressed and that any concerns they had would be listened to. There were systems in place to assess the quality of service provided however there was a need to improve record keeping and to ensure that the auditing processes considered all aspects of the service provided.