Aldergrove Manor Nursing Home

Updated 18 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

This inspection was carried out by two inspectors, a nurse advisor and an Expert by Experience who made calls to people’s relatives. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Aldergrove Manor Nursing Home 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. 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 and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with six people about their experience of care. We also spoke with 14 staff which included the registered manager, senior care staff, care staff and nurses. We spoke to one visiting health professional. Following the inspection, we also spoke with 11 relatives by telephone to gain their views on the service. We reviewed a range of records. This included nine people's care records and multiple medication records. We looked at three staff files in relation to recruitment. A variety of records relating to the management of the service, including medicine audits, care plan audits and the training matrix were also reviewed.

Updated 18 August 2022

About the service

Aldergrove Manor Nursing Home is a residential care home providing personal and nursing care to older people, and younger adults some of whom may have dementia or physical disabilities. The service can support up to 70 people. At the time of the inspection there were 61 people living at the home.

People’s experience of using this service and what we found

The providers systems for ensuring staffing levels at the home were adequate had not been followed to ensure there was enough staff.

We have made a recommendation about assessing the required staffing levels for the home.

The systems for checking medicines administration had not been used effectively to ensure people had enough medicines in stock and medicines administration records required improvement. Medicines were not consistently available for people and medicines administration records required improvement.

Daily charts checks had not been completed to ensure documentation was accurately completed. Care plan evaluations had not consistently been completed to ensure peoples care plans were accurate.

People’s risks and plans for mitigation were not always clearly documented. Staff understood how to keep people safe, they knew how to minimise risks to their safety and could recognise and report any concerns. Staff followed the current guidance for infection prevention control and there was a system in place to learn when things went wrong.

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.

People, relatives and staff had their views sought about the service and these were used to make improvements. The registered manager ensured any incidents were reported to the appropriate agencies.

There was a learning culture in the home and the registered manager ensured staff were fully briefed on any changes made. The registered manager worked with other agencies to seek advice and make improvements to people’s care.

Rating at last inspection

The last rating for this service was good [published 9 June 2021].

Why we inspected

We received concerns in relation to staffing, medicines management, risks management and governance of the home. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe and well led key sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Aldergrove Manor 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 will take further action if needed.

We have identified breaches in relation to the governance arrangements in the home 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.