24 April 2023
During an inspection looking at part of the service
Romsey / Winchester Ave is a care home providing personal care and accommodation for up to 13 adults with mental health needs. The care home is made up of 7 properties, including 3 flats, 1 bungalow, 2 shared houses and a communal office building. At the time of our inspection visit there were 13 people being supported by the service.
People’s experience of using this service and what we found
Overall, the providers systems and processes had identified where improvement was needed. This meant failures to meet regulatory requirements identified at our last inspection had been addressed. However, some audits were not sufficiently robust to identify the concerns we identified during our inspection. This included safe medicine practices.
Improvements had been made and risks to peoples physical and mental health had now been identified and assessed. However, further improvements were needed to ensure known risks were managed well.
Some improvements had been made to the management of environmental risks. Fire doors were now compliant and appropriate window restrictors had been fitted to mitigate the risk of falls from heights. However, action was needed to ensure risks associated with smoking cigarettes were mitigated. This action was taken during our inspection.
Accidents and incidents were recorded but it was not clear what action had been taken to mitigate the risk of these accidents and incidents happening again.
Systems and processes were not always effective. Checks of records had not identified some risks in people’s care. Improvement was needed in the managerial oversight of important records. The provider was responsive to our feedback and took immediate action to rectify some areas of concern.
Despite this, 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 felt safe and protected from the risk of abuse. There were enough suitably skilled staff to provide safe and effective support.
People and relatives were positive about the support people received at the home and of the management and leadership of the service and told us people achieved good outcomes and lived the life they wanted.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 31 December 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
We carried out an unannounced comprehensive inspection of this service on 17 November 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do, and by when, to improve safe care and treatment and good governance.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.
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.
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 remained requires improvement based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Romsey / Winchester Ave on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.