Background to this inspection
Updated
17 September 2021
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 Care Act 2014.
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 two inspectors 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. We visited Alban Manor on 02 July 2021. On 16 July 2021 we met with the provider to discuss the outcome of the inspection and review further evidence submitted to us.
Service and service type
Alban 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.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.
During the inspection
We spoke with six people who used the service and eight relatives about their experience of the care provided. We spoke with 11 members of staff including the provider and registered manager. We reviewed a range of records. This included seven people's care records and multiple medication records. We looked at a variety of records relating to the management of the service.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data, incidents, complaints, compliments and further records relating to the management of the service.
Updated
17 September 2021
About the service
Alban Manor is a residential care home providing personal and nursing care to 47 people aged 65 and over, some of who were living with dementia, at the time of the inspection. The service can support up to 80 people.
Alban Manor accommodates people across two floors in one purpose-built building. Each floor of the building has separate adapted facilities that accommodate people who require nursing, dementia and residential care.
People’s experience of using this service and what we found
People’s risk assessments were not always accurately completed. Care records did not always contain enough detail to provide clear instruction to staff and were not always reviewed when needs changed. Systems to formally review incidents to develop practise and minimise harm were not fully embedded. However, we were satisfied this was an area of governance that required development and had not caused harm to people.
People felt staff were trained. Staff told us had received core areas of training alongside with supervision sessions to discuss their work. However, training, particularly for care staff, required further development in specialist areas. People told us they did not feel their privacy around being able to choose to have their doors open or closed was maintained by staff.
Systems were in place but not always utilised effectively to monitor the quality of care provided. Development was required to ensure meaningful improvement plans were created to capture action identified following audits.
People felt safe living in Alban Manor. Staff knew how to identify and respond if they suspected a person was at risk of harm. Staff reported any incidents to management promptly who took appropriate action. Staff told us there were enough staff deployed in the home to support people. People said there were sufficient staff and were happy living in the home. Infection control procedures were followed and assured safe practices were followed with regards to social distancing and the use of PPE.
People told us they received appropriate support to maintain good nutrition and hydration and the home had good links with other health care professionals.
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 their relatives were actively involved in the development of their care. People were supported to pursue hobbies and interests and supported to avoid social isolation. Staff supported people to communicate their views independently and listened to their opinions. People told us they felt valued.
People's views about the service were sought individually and through meetings and surveys. People and relatives told us the registered manager and provider were approachable and they were confident concerns would be addressed. Staff told us they felt valued by the registered manager and provider.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 08/05/2019 and this is the first inspection.
Why we inspected
This was a planned inspection based on the registration date of the 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.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.
We have identified breaches in relation to accurate maintenance of records and governance at this inspection.
Please see the action we have told the provider to take at the end of this report.
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner. We will work alongside the provider and local authority to monitor progress.