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Coundon Manor Care Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 12 April 2018

This inspection took place on 20 February 2018 and was unannounced.

Coundon Manor is a nursing home. People in care and nursing 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.

The maximum number of people the home can accommodate is 74. The home is a two storey building. People who lived with dementia were supported on the ground floor, and people who were being re-habilitated from hospital on short term contracts, and those living at the home who had more physical nursing needs were supported on the first floor.

At our last inspection the home was placed into Special Measures. This was because we had rated the key questions of 'safe,' ‘responsive’ and 'well-led' as inadequate. There were seven breaches of the Regulations. At that time we met with the provider and they provided us with an action plan. This showed what they would do and by when, to improve all areas of the service we had concerns with to at least 'good'. The provider liaised with us by updating the action plan informing us when they had achieved their aims and what outcomes continued to require improvements.

During this visit the provider had made a promising start to improving the service and the home was no longer in breach of the regulations, and no longer in special measures.

Because it had only been four months since our last visit we were aware the provider had not had a significant period of time to move the home forward and sustain improvements made. The provider also shared this view. They had also been made at a period of time when there were less people in the home than usual. This was because the provider had volunteered to stop admitting new people to the home until improvements were made.

At our previous inspection to the service, 70 people lived at Coundon Manor; during this visit 49 people lived at the home. Improvements were required to be sustained over a period of time once further people were admitted to the home.

The registered manager had been the registered manager at Coundon Manor since 2016. 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.

Staffing levels had increased, and there had been a reduction in the high number of agency staff used. New staff were still becoming familiar with the service and the needs of people who lived at the home. Staff were deployed in specific areas of the home to supervise people in order to promote people's safety and to reduce the risks of people falling.

Care records provided more detail about people, and risks related to people's health and well-being were now being appropriately assessed and acted on. New equipment had been bought to improve the responsiveness of care and to reduce people's risks.

The premises and equipment were clean.

The mealtime experience had improved and people who were at risk of malnutrition or dehydration were getting more support from staff to encourage them to eat and drink healthily. Checks were now being undertaken to identify when people had not eaten or drank so staff could provide further encouragement.

Staff now received better access to training and support. Many staff had completed the provider's accredited dementia training and dignity training, as well as the expected health and safety training. We saw improved responses from staff in relation to people with dementia, and in respecting people's dignity and privacy.

Medicines were mostly managed safely, and the provider had a good understanding of what improvements were required to manage medicines more safely and effectively. Staff recruitment procedure

Inspection areas


Requires improvement

Updated 12 April 2018

The service was mostly safe.

Improvements had been made in the number of staff available to support people on each shift, and there had been a reduction in the number of agency staff used. Improvements had been made in the assessment and implementation of risk reduction strategies to support people’s safety. Medicines were mostly managed well. Staff recruitment measures reduced the risk of employing unsuitable staff. Improvements had been made in the cleanliness of the home and the equipment people used.


Requires improvement

Updated 12 April 2018

The service was mostly effective.

Staff training had improved, and new starters were now receiving an effective induction to the home, although not all new staff were yet sufficiently skilled and experienced. Staff understood the importance of receiving people's consent to care and treatment and worked within the Mental Capacity Act and Deprivation of Liberty regulations. Peoples experience at meal times had improved, as had staff support for people who were at risk of malnourishment or dehydration. People received access to healthcare when necessary.



Updated 12 April 2018

The service was caring.

Staff were kind and caring to people, They had received 'dignity training' and were aware of how to treat people with dignity and respect. Because of an increase in staff numbers they had time to meet people's emotional and social needs and to promote people's independence. Visitors were welcomed in the home.


Requires improvement

Updated 12 April 2018

The service was mostly responsive.

People had started to have their needs responded to in a timely way. Care plans had been updated and were now centred on the needs and preferences of each person. Complaints were now being responded to in line with the provider's policy and procedure. Staff who worked in the dementia unit had, or were scheduled to receive, specialised dementia care training to provide more responsive dementia care.


Requires improvement

Updated 12 April 2018

The service was becoming well-led.

Since our last inspection the provider had provided more effective support to the registered manager and staff to make improvements to the service. Quality systems had changed and this had improved the responses of the service in dealing with issues which arose. The improvements were relatively recent, and had not been tested over a longer period of time and with a home at full capacity to ensure sustainability.