5 January 2022
During a routine inspection
People’s experience of using this service
Some aspects of the service were not always safe or consistently well-managed. This meant people living at the care home were placed at unnecessary risk of harm. This was because the oversight and scrutiny systems the provider had in place were not always operated effectively. For example, the provider had failed to identify and/or take appropriate timely action to address a number of issues we found at this inspection that related specifically to risk management, fire safety, infection prevention and control (IPC) and building maintenance. The provider needs to take action to ensure their quality monitoring and governance audits are effectively operated so they can learn lessons and continuously improve the service people living at the care home receive.
In addition, the care home had been without a suitably competent person in day-to-day charge since April 2021. We discussed this ongoing management issue with the owner at the time of our inspection. They agreed they would appoint a competent manager and ensure they applied to be registered with us by April 2022. Progress made by the provider to achieve this stated aim will be closely monitored by the Care Quality Commission (CQC).
The service was not always effective at achieving good outcomes for people. This was because the provider had failed to assess and do all that was reasonably practicable to minimise the risks of people with mobility needs safely accessing the rear garden. The provider needs to make accessing the rear garden safe for all.
The service was not always responsive to meeting peoples needs. This was people did not always have sufficient opportunities to choose to participate in meaningful leisure and recreational activities that reflected their social interests and wishes. We have made a recommendation about improving activities that people living in the care home can choose to engage in, both within the care home and the wider community.
People were protected against abuse and neglect. The service was adequately staffed by people whose suitability and fitness to work in an adult social care setting had been properly assessed. Medicines systems were well-organised, and people received their prescribed medicines as and when they should.
People were well cared for by staff who had the right levels of training and support to deliver it. 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. People were supported to access food and drink that met their dietary needs and wishes. People were supported to stay healthy and access community-based mental health and social care professionals as and when required.
People were treated equally and had their human rights and diversity respected. Staff treated people with respect and dignity and upheld their right to privacy. People were supported to maintain and develop their independent living skills. People were encouraged to make decisions about the care and support they received and had their choices respected.
Up to date, person centred, electronic care plans were in place for everyone who lived at the care home, which helped staff to meet their personal, emotional, health and social care needs. Staff ensured they communicated and shared information with people in a way people could easily understand. People were supported to maintain relationships with family and friends. People’s concerns and complaints were listened to and investigated by the provider. Plans were in place to help people nearing the end of their life receive compassionate palliative care in accordance with their needs and wishes.
The provider promoted an open and inclusive culture which sought the views of people living in the care home, their relatives, community-based health and social care professionals and staff working there. The provider worked in close partnership with various external health and social care professionals and agencies to plan and deliver people’s packages of care and support.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at the last inspection
This service has a new legal entity and was reregistered with us on 30 June 2020. This is their first inspection since reregistering with us. The last rating for the service under the previous provider was good (published 21 May 2018).
At this inspection we found multiple breaches of regulations and the need for this provider to make improvements. Based on the findings at this inspection the overall rating for the service is requires improvement.
Why we inspected
This was a planned comprehensive inspection based on the service having a new legal entity and reregistering with us.
Enforcement
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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified two breaches at this inspection because the provider had failed to always identify and safely manage risks people living in the care home might face, and effectively operate their oversight and scrutiny systems.
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 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.