Archived: St Catherine's Manor

Updated 31 October 2018

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, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 26 September 2018 and was unannounced. The inspection was carried out by two inspectors, a specialist advisor who had a background in nursing and an 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

Before the inspection the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We reviewed the PIR and other information we held about the service. This included past reports and notifications. A notification is information about important events which the service is required to send us by law.

We spoke with a range of people about the service; this included seven people who lived at St Catherine’s Manor, four relatives, and two professionals who had regular contact with the service. During the inspection we spoke with six staff members, the registered manager and regional manager.

We looked at care records of eight people who lived at the service and recruitment records of three staff members. We also looked at records relating to the management of the service. In addition, we checked the building to ensure it was clean, hygienic and a safe place for people to live.

Updated 31 October 2018

The inspection took place on 26 September 2018 and was unannounced.

St. Catherine’s Manor is a 'care home'. People in care 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. St. Catherine’s Manor provides facilities and services for up to 34 people who require personal or nursing care. At the time of our inspection there were 26 people living at the service. The majority of people living at St. Catherine’s Manor are living with dementia. The accommodation is provided over two floors which are accessible by stairs and a lift.

Since our last inspection a new manager had been appointed who had registered with CQC. 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 were protected from the risk of abuse as staff understood their responsibilities in safeguarding people. The provider had systems in place for reporting concerns and records showed that these were followed. Risks to people's safety were assessed and control measures implemented in order to keep them safe. Accidents and incidents were recorded and monitored. Action was taken to minimise the risk of reoccurrence and an analysis completed to identify possible trends. The provider had developed a contingency plan to ensure that people would continue to receive their care in the event of an emergency. The service was clean and well maintained. Staff understood their responsibility to protect people from the risk of infection and followed safe procedures.

People were supported by sufficient staff to meet their needs and did not need to wait for their care to be provided. Prior to staff starting their employment robust recruitment processes were completed to ensure they were suitable to work within care services. Staff received an induction when starting work at the service and did not work without supervision until they were confident in their role. Staff received regular training and supervision to support them in their role.

People received their medicines in line with prescription guidelines and medicines were stored safely. Healthcare professionals were positive about the service and care records showed the service worked with a range of healthcare professionals. People's weight was regularly monitored and a choice of nutritious food provided. People were involved in decisions regarding their care and the principles of the Mental Capacity Act 2005 were followed by staff.

Staff treated people with kindness and had formed positive relationships with people. There was a relaxed atmosphere in the service and staff spent time socialising with people. People’s dignity and privacy were respected and people were encouraged to maintain their independence. People’s religious and cultural needs were respected. Visitors were made to feel welcome and there were no restrictions on visiting times.

People's needs were assessed prior to them moving into St. Catherine’s Manor and people's care records were regularly reviewed. Guidance was available to staff regarding how people preferred their care to be provided and we observed this was followed. The care people received at the end of their life was person centred and reflected their wishes. A range of activities were provided although people told us there had been a reduction in the quality of these. We have made a recommendation regarding this. There was a complaints policy which gave guidance on how to raise concerns which was prominently displayed. People and relatives told us they were confident that any concerns would be addressed by the registered manager

There was an open culture within the service and staff felt able to discuss any concerns openly with the registered manager and provider. Quality assurance systems were in place to monitor the service provided and action was taken where shortfalls were identified. People, relatives and staff were asked for feedback on the service provided and suggestions were acted upon. The service worked with external agencies to ensure service development and learning.