Vaughan Lee House

Updated 17 August 2023

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 2008.

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 completed by 2 inspectors.

Service and service type

Vaughan Lee House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Vaughan Lee House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was 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 the last inspection. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We observed how staff provided support for people, to help us better understand their experiences of the care they receive. We spoke with 9 people who lived at the home and 12 members of staff including the registered manager, deputy manager and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spoke with 2 relatives about their experience of the care provided, and a visiting professional.

We reviewed a range of records relating to people’s individual care and records relating to the running of the home. This included 6 people’s care records, a sample of medication administration records and a variety of records relating to the management of the service, including a sample of recruitment files, policies, and procedures.

Updated 17 August 2023

About the service

Vaughan Lee House is a residential care home providing personal care to up to 30 people. The service provides support to older people. At the time of our inspection there were 24 people using the service.

People’s experience of using this service and what we found

People's records did not always contain all the information staff needed to provide safe care. Some individual risks to people were not always thoroughly assessed and mitigated, and records relating to people's care were not always complete and reviewed.

The medicines system was not always robust. The recording of topical creams administration was not completed. Some people were prescribed medicines to be taken when required, there was a lack of guidance when this medicine should be administered.

People were not always supported to have maximum choice and control of their lives. The service could not always demonstrate they were working within the principles of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

Recruitment procedures were not always robust, and staff did not always have appropriate training, support and detailed guidance to ensure people received safe care at all times.

The governance systems had failed to identify the areas for improvement that we found during the inspection. The shortfalls identified did not have any impact on the care and support people received. We discussed our concerns with the nominated individual and registered manager who were responsive to our feedback and started to take action to address the issues identified.

Staff understood how to protect people from poor care and abuse. Staff had training on how to recognise and report abuse and they knew how to apply it.

People told us they were happy; they felt safe, and the staff were kind and caring. Throughout the inspection we observed kind, relaxed, compassionate, and caring interactions between people and staff. Activities were provided for people, and they were supported to spend their time how they chose.

Rating at last inspection

The last rating for this service was good (published 18 May 2019).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, safeguarding (DoLS), staff training and support and good governance at this inspection.

We have also made recommendations in relation to medicines, recruitment and need for consent.

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.