Background to this inspection
Updated
24 February 2022
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.
As part of CQC’s response to care homes with outbreaks of COVID-19, we are conducting reviews to ensure that the Infection Prevention and Control (IPC) practice is safe and that services are compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.
This inspection took place on 17 February 2022 and was announced. We gave the service 24 hours’ notice of the inspection.
Updated
24 February 2022
About the service
Four Seasons is a purpose-built care home, registered to provide care for up to a maximum of 121 people. The home provides residential, nursing, residential dementia and nursing dementia care and is split into five wings. On the day of the inspection there were 99 people using the service. One area specialised in providing nursing care for people living with dementia, other areas specialised in providing residential care and dementia care.
People’s experience of using this service and what we found
People's needs were assessed before starting with the service. People and their relatives, where appropriate, had been involved in the care planning process.
Risks to people's health and wellbeing were assessed and mitigated, however, people's medicines were not always managed safely.
The provider followed safe recruitment processes to ensure the right people were employed. There were enough staff to keep people safe.
People were protected from abuse. Staff understood how to recognise and report any concerns they had about people's safety and well-being.
The home was clean, and staff followed procedures to prevent the spread of infections.
The provider and registered manager followed governance systems which provided oversight and monitoring of the service. More robust quality assurance systems were now in place to ensure any shortfalls were identified and to drive continuous improvement within the service.
When required, people were supported to access healthcare professionals and receive ongoing healthcare support. People were supported to share their views and shape the future of the care they received.
Care plans provided staff with the information they needed to meet people's needs. People could choose how they wanted to spend their time. Staff worked with other agencies to provide consistent, effective and timely care. We saw evidence that the staff and management worked with other organisations to meet people's assessed needs.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection (and update)
The last rating for this service was Requires Improvement (published 15 October 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been sustained and the provider was still in breach of regulations. This service has been rated requires improvement for the last two consecutive inspections.
Why we inspected
We carried out an unannounced comprehensive inspection of this service on 17 and 18 July 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, person-centred care, staffing and good governance.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain some of those requirements.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has not changed. This is based on the findings at this inspection.
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 coronavirus and other infection outbreaks effectively.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Four Seasons on our website at www.cqc.org.uk.
Follow up
We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.