Background to this inspection
Updated
24 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
This inspection was carried out by one inspector
Service and service type
Ermington 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. Ermington 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 not a registered manager in post.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We reviewed information we held about this service since the last inspection. We reviewed information we had received from health professionals and the local authority. We used all this information to plan our inspection.
During the inspection
We spoke with 8 people who live at the service and 4 relatives. We spoke with the new manager, a senior manager supporting the new manager, the operations manager, the provider and 8 staff including the cook and house keeper. We reviewed a range of records related to the service people received. This included 6 peoples's care plans and medicines administration records, staff training records, 3 staff recruitment records and various audits
in place to oversee and monitor the service.
Updated
24 August 2023
About the service
Ermington House is a residential care home providing personal care to up to 34 people. The service provides support to people aged 65 and over. At the time of our inspection there were 24 people using the service.
People’s experience of using this service and what we found
Risks to people's health and safety were assessed and guidance was in place to manage risk. However, monitoring records did not always show that people were receiving care according to their assessed needs.
Whilst quality assurance and governance systems were in place to monitor the quality-of-care people received, the providers audits and checks had not identified the shortfalls we found regarding people’s monitoring records.
During the inspection we observed people were supported by enough staff to meet their needs safely. However, we received mixed feedback from people and staff about staffing levels and some people told us they had to wait for their needs to be met. We made a recommendation to the provider about this.
People spoke positively about the service and told us they were happy with the support they received. People were complimentary about the staff and told us they felt safe living at Ermington House.
Systems and processes were in place to protect people from the risk of infections. People were supported to receive visitors at the service when they wanted.
Medicines were managed safely, and people received their medicines from trained and competent staff. Staff were recruited safely.
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.
Systems were in place to review and analyse accident and incident records to identify any trends so action could be taken to reduce the risk of avoidable harm.
People and their relatives had opportunities to provide feedback in the form of questionnaires, feedback forms and regular meetings.
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 this service was good. (Published 6 January 2021).
Why we inspected
The inspection was prompted in part due to concerns received about poor care, staffing levels, infection control and medicines management. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ermington House on our website at www.cqc.org.uk.
Enforcement
We have identified breaches in relation to managing risk and the providers governance systems at this inspection.
We also made a recommendation in relation to staffing levels.
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.