Background to this inspection
Updated
11 August 2016
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.
The inspection was unannounced and was undertaken by a two adult social care inspectors. At the last full inspection of Sedbury Park in November 2015 we found three breaches of regulations. The breaches were in respect of safety in parts of the home, a lack of adherence to the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards and inaccurate or incomplete care planning documentation. The provider sent us their action plan following the inspection and told us what they were going to do to put things right.
Prior to the inspection we looked at information about the service including notifications and any other information received by other agencies. Notifications are information about specific important events the service is legally required to report to us. We had not asked for the Provider Information Record (PIR) to be completed prior to this inspection however we had the PIR that had previously been submitted. The PIR was information given to us by the provider. This is a form that asks the provider to give some key information about the service, tells us what the service does well and the improvements they plan to make.
During our inspection we spoke with 11 people living at Sedbury Park and three relatives. We spoke with the interim manager and 13 other members of staff. This included qualified nurses, care staff, catering staff, domestic staff and the activity coordinators. During the inspection we spoke with one healthcare professional who was visiting the home. You can see what they told us in the main body of the report.
Not everyone was able to tell us their experiences of life at the home. This was because of their dementia or complex nursing needs. We therefore spent time observing people and the staff that were supporting them. We 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 to us.
We looked at six people’s care documentation, two from each of the three units. We checked other records relating to how staff monitored people’s health and the care delivery. This included food and fluid charts, repositioning charts and medicine records. We looked at the recruitment files of three new staff who had started working at the home since our last inspection. Other records included staff training records, key policies and procedures, audits, quality assurance reports and minutes of meetings.
Updated
11 August 2016
This inspection took place on 28 and 29 June 2016. Sedbury Park is located near the Wales and Gloucestershire border a short distance from Chepstow. The home is registered to accommodate up to 105 older people although there were only 74 usable rooms. The home is surrounded by 12 acres of private land, with views over the estuary and the two Severn Bridges.
The main part of the house is a grade II listed building plus an extension. Parts of this building were in a poor state of repair but there was a refurbishment plan in place. There was also two purpose built units called Marlings and the Wye Unit. The three units could accommodate 28, 21 and 25 people respectively. There were 60 people in residence at the time of our inspection. All private bedrooms have en-suite facilities.
There was no registered manager in post but the provider had appointed an interim manager to oversee the running 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. The interim manager will be making application to CQC to be the registered manager until a permanent manager can be appointed.
Whilst we found the premises to be clean on this inspection, the service did not have measures in place to ensure that infection control and prevention procedures were adequate. No infection control audits had been completed and there were no records of checks of equipment to ensure it was clean. However, a hand-washing audit had been completed in March 2016.
People’s rights may not be protected because staff did not act in accordance with the Mental Capacity Act 2005. Applications to deprive a person of their liberty in their best interests had been submitted but this had not been completed in all appropriate cases. Whilst the staff team understood the need to obtain consent from people regarding day to day decisions, their knowledge of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS) was limited. Staff were not clear who had an authorised DOLS in place.
Care planning documentation had improved since the last inspection however on Wye unit particularly the reviewing of care plans and risk assessments was not consistent. Further improvements were required to ensure that for each person, there was an accurate and detailed care plan stating how their care and support need were to be met. Despite this, people said they received the care and support that met their specific needs.
All staff received safeguarding adults training and were knowledgeable about safeguarding issues. They knew what to do if bad practice was witnessed, alleged or suspected and would take the appropriate actions. The manager was fully aware of reporting procedures and had reported a number of events promptly to the local authority and CQC. The appropriate steps were in place to protect people from being harmed. There were safe recruitment procedures in place to ensure unsuitable staff were not employed.
The arrangements in place to ensure the premises were safe had been improved. Contractual arrangements were in place for the servicing and maintenance of equipment and there was a programme of environmental checks completed on a weekly or monthly basis. A range of risk assessments were completed for each person and appropriate management plans were in place. Medicines were well managed.
Staffing numbers were based upon the care and support needs of each person in residence, although the manager did not use any formulae to determine safe staffing levels. The service were in the process of reviewing staffing levels in Wye unit based on feedback from the staff team and relatives.
New staff were expected to complete an induction training programme but this had been hit and miss prior to the new manager starting. For all staff there was a programme of essential training to enable them to carry out their roles and responsibilities but the records of who had done what was out of date. The manager was already aware of this shortfall and had already taken action to rectify this. Care staff were encouraged to complete nationally recognised qualifications in health and social care.
People were provided with sufficient food and drink. Their specific dietary requirements were catered for and there were measures in place to reduce or eliminate the risk of malnutrition or dehydration. Arrangements were made for people to see their GP and other healthcare professionals as and when they needed to.
The staff team were described as kind and friendly and had good caring relationships with the people they were looking after. People were able to participate in a range of different activities and external entertainers regularly visited the home. People were encouraged to be as independent as they were able and were involved in having a say about how they wanted to be looked after.
The staff team were responsive to people’ individual needs and the care planning processes were on the whole sufficient. Improvements were required with the care planning documentation in Wye unit. Many of the plans had not been transferred to the new documentation and the reviews had not consistently been carried out.
Regular staff meetings were now scheduled as a means to provide good leadership and management of the service. This ensured the staff team were kept up to date with any changes and developments in the service and knew what was expected of them. The provider had a regular programme of audits to complete to check on the quality and safety of the service. Some of the checks were completed on a daily basis, others on a weekly or monthly basis.
We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.