Background to this inspection
Updated
17 December 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 2014.
This was a targeted inspection to check whether the provider had met the requirements of the Warning Notice in relation to Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
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
The inspection was carried out by 2 inspectors, a specialist advisor and an Expert by Experience. Our specialist advisor was a registered nurse who had expertise in supporting older people and people living with dementia. 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
Coundon Manor 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.
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 not 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 our last inspection and sought feedback from the local authority who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all of this information to plan our inspection.
During the inspection
We spoke with 10 people who lived at Coundon Manor and 2 people's relatives to find out what it was like to live at the home and to gather their experience of the care provided. We spoke with 12 members of staff including the managing director, the manager, the deputy manager, one of the providers quality improvement leads, nurses, senior care assistants, care assistants and a member of housekeeping staff. We observed some of the care and support provided in communal areas.
We reviewed 5 people's care records, 19 people’s supplementary records and multiple medication records. We reviewed some of the provider’s policies and procedures.
Updated
17 December 2022
About the service
Coundon Manor is a care home and is registered to provide personal and nursing care for up to 74 older people. At the time of our inspection 43 people lived at the home and one person was in hospital. Accommodation is provided in a purpose-built home across two floors. One floor provides specialist care to people who live with dementia.
People’s experience of using this service and what we found
Risks associated with people’s care were not consistently assessed and well managed. Medicines were not always managed safely and in line with the providers policy. Despite these shortfalls, people felt safe living at Coundon Manor. Staff were recruited safely, and enough staff were on duty to meet people’s needs and provide safe care.
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 provided positive feedback about the food and staff knew what people liked to eat and drink and understood people’s dietary requirements.
Quality assurance checks were not always effective and robust enough to provide effective oversight of the service. As they had failed to identify the issues we found, such as gaps in the call bell audits.
A service improvement plan was under constant review, while the provider had addressed some of the concerns raised at our last inspection. Further improvement was required, to ensure people consistently received safe care and support. New systems and processes introduced also needed time to fully embed to ensure they were sustained.
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 20 July 2022) and there were breaches of regulation. The provider had received a warning notice following the last inspection and they had to be compliant with this. The provider was also required to send us an action plan telling us how they would improve and by when. At this inspection enough improvement had not been made and the provider was still in breach of regulations.
The overall rating for the service has remained requires improvement. This service has been rated requires improvement for the last two consecutive inspections.
Why we inspected
We undertook this focused inspection to follow up on action we told the provider to take at the last inspection. This report only covers our findings in relation to the key questions safe, effective and well-led which contain those requirements. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
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.
We have found evidence that the provider needs to make improvements. Please see the safe, effective 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 full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Coundon Manor 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 people’s safety and the governance of the service. We found the provider failed to meet the warning notice we issued at the last inspection.
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.
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.