Background to this inspection
Updated
22 August 2020
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.
Inspection team
The inspection was carried out by two inspectors and two assistant inspectors. Two inspectors carried out a site visit, whilst two assistant inspectors made telephone calls with relatives and staff.
Service and service type
Windsor Park Nursing Home 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 registered with the Care Quality Commission. 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.
Notice of inspection
This inspection was unannounced. Prior to entering the location we assessed risks associated with Covid-19.
What we did before the inspection
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.
We reviewed information we had received about the service since the last inspection. This included any notifications we had received from the service (events which happened in the service that the provider is required to tell us about). We reviewed the last inspection report. We also sought feedback from the local authority and local clinical commissioning group. We used all of this information to plan our inspection.
During the inspection we spoke with eight relatives or friends of people who used the service about their experience of the care provided. We also spent time with people who used the service and observed the support they received. We also used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with eight members of staff and the registered manager, deputy manager and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
We reviewed a range of records. This included in part, eight people's care records. We looked at four staff files. We reviewed a variety of records relating to the management of the service, including accidents and incidents, six people’s medicine records, audits, and checks on health and safety.
After the inspection we continued to seek clarification from the provider to validate evidence found. This included but was not limited to the provider’s current action plan, training data, policies and procedures and meeting records.
Updated
22 August 2020
About the service
Windsor Park Nursing Home is a care home registered to provide personal care for up to 19 people who have nursing care needs, including people living with dementia. At the time of our inspection, there were 14 people living at the service. Accommodation was provided over two floors and a passenger lift was available.
People's experience of using this service and what we found
People were at risk of harm. Risks associated with people's care and treatment needs, including how clinical needs were assessed, monitored and managed were of significant concern. Guidance for staff about how to meet people's individual care and treatment needs either lacked detail or was not available for staff.
Clinical leadership and oversight at the service was insufficient as a result of both the registered manager and clinical lead being away from the service for prolonged periods due to the Covid-19 pandemic. The new director of the provider company and nominated individual had only recently taken over management of the service. There was some evidence of clinical supervision and competency assessments of nursing staff, however, these were not always documented sufficiently. This impacted on people receiving safe care and treatment.
There were no systems or processes in place to review incidents or any analysis completed that may have identified any themes or patterns to reduce reoccurrence. A failure to take action to learn from incidents impacted on people’s safety.
People’s dependency needs had not been assessed since 2019. This meant it was difficult to establish if staffing levels were sufficient to meet people’s individual needs and safety.
Staff lacked specific training in some areas, impacting on people’s care needs being fully known, understood or effectively met by staff at the service. Safe staff recruitment and induction procedures had not always been completed, exposing people to potential harm.
The procedures for staff to exchange information about people’s care and treatment needs was not safe or effective.
The environment, including furnishings were worn and needing redecoration and refurbishment. The Provider identified this issue within their action plan and planned to refurbish the home within the next six -twelve months. Infection prevention and control procedures reflected the Covid-19 pandemic guidance. People received their prescribed medicines when they needed them.
Systems and processes to assess and monitor quality including health and safety had not been fully kept up to date. This included audits and checks in relation to medicines, care plans and risk assessments.
Following the inspection, the provider sent us an action plan based upon the main issues found at this inspection. The impact of the planned actions will be assessed at our next inspection.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was Good (Published 28 December 2018). The rating for the service has changed from Good to Inadequate. This is based on the findings at this inspection.
Why we inspected
We received concerns in relation to the management, oversight and governance of the service, including staffing and clinical competency. Many of these issues had occurred as a result of the Covid-19 pandemic. We raised these concerns pre-inspection with the provider, but were not sufficiently assured. As a result, we undertook a focused inspection to review the key questions of 'Safe' and 'Well-led' only
We received concerns in relation to the management, oversight and governance of the service, including staffing and clinical competency. We raised these concerns pre-inspection with the provider, but were not sufficiently assured. As a result, we undertook a focused inspection to review the key questions of ‘Safe’ and ‘Well-led’ only.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them.
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 report.
Enforcement
We have identified two breaches in relation to safe care and treatment and good governance.
Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.