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Coundon Manor Care Home Good

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Inspection report

Date of Inspection: 16 June 2014
Date of Publication: 19 July 2014
Inspection Report published 19 July 2014 PDF


Inspection carried out on 16 June 2014

During a routine inspection

This service was inspected by four inspectors including a pharmacist inspector and an inspection manager. The inspection focused on concerns we had received about the service. The inspection covered parts of the night and day shifts. This was to enable us to see how people were being cared for and supported across the whole day. It was also to enable us to talk with a wide range of staff, people who used the service and their relatives or friends. Many of the people who lived at Coundon Manor were not able to tell us about their experiences of the home. We spoke with six people who lived at the home, two relatives, five nurses, eleven care assistants, a cleaner and a kitchen assistant. We also spoke with management staff.

We looked at five outcomes to answer the following five questions. Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our findings during the inspection, speaking with people who used the service, the staff supporting them and from looking at records. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

People we spoke with were positive in their comments about the service but we found improvements were needed in the care and support being provided.

People were not always involved in their care. We saw people�s care records were not always accurate or sufficiently detailed to make sure people received the care they needed.

Staff had received or were booked onto training about the Mental Capacity Act. This was to improve their understanding of how to support people who lacked mental capacity to make decisions about their care and treatment. The manager told us further work was needed to check if any Deprivation of Liberty Safeguards (DoLS) applications needed to be made.

Effective systems were not in place to make sure staff learned from events such as accidents and incidents, complaints, concerns and investigations.

We found staff were not always knowledgeable about people�s needs. We were told by staff that they did not always have time to read care plans. We found the number of staff available to support people and the way staff were organised was not always effective to keep people safe.

There were ongoing problems with people�s medicines not being available. We were told this was primarily due to problems in communication between the doctor�s surgery and the supplying pharmacy. Although we acknowledged the problem involved a number of agencies, effective action had not been taken to resolve it. We found that people�s medicines were not always available to give to people as prescribed. This increased medicine safety concerns. We found appropriate arrangements were not in place to manage the risks associated with the unsafe use and management of medicines.

Is the service effective?

We saw there was a process to assess risks associated with people�s care. We found this process was not being managed consistently. We found in particular risks associated with people�s nutrition were not always effectively managed.

People had access to a range of health care professionals to support their care needs, some of which, visited the home.

We found some of the equipment needed to support people�s needs was not readily available.

Is the service caring?

We saw staff were attentive to people's needs throughout our inspection. We saw some staff were kind and friendly in their approach. Others were task orientated and seemed rushed and unable to spend time with people. We spoke with a number of people who used the service. People told us they were satisfied with the care and support they received. One person told us, �I�m very comfortable and well looked after.�

Is the service responsive?

People were able to participate in social activities within the home and within the local community. One person told us, �They throw balls and do painting.� We saw social activities being undertaken on the day of our inspection.

There was not an effective system in place to manage complaints. This had been identified and the new management team were in the process of addressing complaints received.

We found systems and processes were not in place to analyse accidents and incidents to identify any preventative measures required.

We saw people were able to access help and support from other health and social care professionals when necessary.

Is the service well led?

At the time of our inspection the manager named on this report was no longer in post. A new manager had been employed and was to complete the CQC registration process.

We did not see there was an effective system to monitor the quality of care and services provided. We were told about plans in place to address this. These plans included the implementation of quality audits of the service.

We saw there was a new management team in place at the home. We saw actions were in progress to make improvements across the home. Staff were positive about the actions that the management team had taken since they had been in post.