Background to this inspection
Updated
22 February 2024
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.
Inspection team
The inspection was carried out by 1 inspector, 1 medicines inspector and 1 Expert by Experience. 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
Hyde Lea 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. Hyde Lea 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 not a registered manager in post. The previous manager had left before registering with the Care Quality Commission. The provider was in the process of identifying a replacement and was undertaking the role of manager in the interim.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
Prior to the inspection we reviewed information and evidence we already held about the home, which had been collected via our ongoing monitoring of care services. This included notifications sent to us by the home. Notifications are changes, events or incidents that the provider is legally obliged to send to us without delay. We also asked for feedback from the local authority and professionals who work with the home. 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 of this information to plan our inspection.
During the inspection
We spoke with 3 people and 4 relatives about the home and the care provided. We also spoke with 6 members of staff, which included the owner, who was currently managing the home, a deputy manager and care staff. We sought the views of 3 more staff via an emailed questionnaire.
We looked at 3 people’s care plans and risk assessments. We also looked at medicines and associated records for 6 people. We reviewed a range of documentation which included, safety records and certification, supplementary charts, audit and governance information.
After the inspection
We requested and reviewed additional evidence from the provider. This included accident information, evidence of notifications, risk assessments and additional care plan information.
Updated
22 February 2024
About the service
Hyde Lea is a family operated residential care home registered to provide support for up to 19 people, most of whom are living with a dementia. The home is a large, detached property set within its own grounds which has been extended. At the time of inspection 19 people were living at the home.
People’s experience of using this service and what we found
We found improvement was required with record keeping, comprehensiveness of some people's care plans and risk assessments and with the provider’s governance processes. We have made a recommendation about medicines guidance.
People felt safe living at Hyde Lea. Staff knew people well and how to keep them safe. People and relatives provided positive feedback about the staff, how they provided care and met people’s needs. Training in safeguarding was provided and refreshed. Staff knew how to identify and report any concerns. Enough staff were deployed to meet people’s needs and keep them safe, with existing staff used to cover sickness or other absence, to ensure continuity of care. Accidents, incidents and falls had been documented along with actions taken, although we saw no evidence analysis had been completed to look for trends and consider any learning from these. The provider had appropriate infection control policies and procedures in place. 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 and relatives described staff as kind and caring. Staff knew people well and how they wanted to be cared for. People were treated with dignity and respect and where able, allowed to complete tasks for themselves to maintain their independence.
People, relatives and staff spoke positively about the home. A number of relatives had moved their family member to the home after negative experiences at other care homes and stated how much happier, they and their relative now was. People’s views were sought via annual questionnaires. Due to the majority of people at the home living with a dementia, the provider felt resident meetings were not the best way to involve people, so views were sought more informally through discussion with people and relatives. Relatives told us they were happy with communication.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for the service was good (published April 2018).
Why we inspected
We undertook this focused inspection to assess whether the current rating of good was still accurate. The inspection was also prompted in part by an incident, which resulted in a person sustaining a serious injury. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident.
This report only covers our findings in relation to the key questions safe, caring and well-led, as these were the only key questions inspected. For those key questions not inspected, we used the ratings awarded at the last comprehensive inspection to calculate the overall rating. The overall rating for the service has remained good based on the findings at this inspection.
Enforcement and Recommendations
We have identified a breach in relation to record keeping and governance processes at this inspection.
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.