Visitation of Our Lady Residential Care Home

Updated 23 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 the COVID-19 pandemic we are looking at how services manage infection control and visiting arrangements. This was a targeted inspection looking at the infection prevention and control measures the provider had 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 18 January 2022 and was announced. We gave the service 24 hours’ notice of the inspection.

Updated 23 February 2022

This unannounced inspection took place on 24 October 2017. The service was last inspected on 4 October 2016 when we found two breaches of the Health and Social Care Act 2008 and associated regulations relating to Safe Care and Treatment and Good Governance. We also made recommendations in relation to the management of incidents and accidents and training. Following the inspection the provider sent us an action plan detailing how they would make improvements. At this comprehensive inspection we found the provider had taken action to address the breaches we had identified and improvements had been made.

Visitation of Our Lady Residential Care Home offers personal care for up to nine older people and is run by a Roman Catholic Polish Community. At the time of our inspection, five people were living at the service. The staff lived at the home and were a community of nuns from Poland.

There was a registered manager in post at the time of our inspection. 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.

People received their medicines safely. Staff received training in the administration of medicines and there were regular medicines audits.

People and staff told us they felt safe and there were systems and processes in place to protect people from the risk of harm.

There were enough staff on duty to care for people because staff lived at the service and were always available.

There were appropriate procedures in place for the safeguarding of people at risk of abuse and these were being followed.

There were systems in place for the management of incidents and accidents and appropriate action was taken to reduce the risk of reoccurrence.

People were supported by staff who were trained, supervised and appraised. The registered manager attended provider forums in order to keep abreast of developments within the social care sector.

People’s nutritional and healthcare needs had been assessed and were met.

The provider acted in accordance with the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS). People’s capacity was assessed and where they could, they had consented to their care and support. Where people lacked capacity, we saw that best interests decisions were made. Processes had been followed to ensure that, where needed, people were deprived of their liberty lawfully.

People and their relatives told us that the staff and registered manager were caring and communicated effectively with them, responded to their needs promptly and treated them with kindness and respect. The staff team knew people well and delivered care that made people feel valued. The whole staff team promoted person centred values as the basis of the service and ensured these were followed at all times.

The whole staff team understood the importance of ensuring people’s emotional, spiritual and cultural needs were met as well as their physical needs.

Care plans were in place and people had their needs assessed and reviewed regularly. Care plans contained information that reflected the needs and wishes of the individual.

There was a complaints procedure in place and people and their relatives knew how to make a complaint. They felt confident that their concerns would be addressed.

People and relatives were given questionnaires to gain their feedback on the quality of the care provided.

People, relatives and professionals we spoke with thought the home was well-led. The staff told us they felt supported by the registered manager and there was a family atmosphere and a culture of openness and transparency within the service.

The provider and registered manager undertook regular safety audits and action was taken when issues were identified.