Formby Manor Care Centre

Updated 23 August 2022

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

The inspection was carried out by two inspectors, a medicines inspector and a specialist nurse advisor.

Service and service type

Formby Manor Care Centre 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. Formby Manor Care Centre is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

At the time of our inspection there was not a registered manager in post. However, there was a manager at the home who planned to register with the CQC.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. 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 (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 this information to plan our inspection.

During the inspection

We spoke with five people who used the service and three relatives about their experience of the care provided. We spoke with nine members of staff including the manager, head of care, deputy manager, nurses, senior care workers and care workers.

We reviewed a range of records. This included eight people’s care records, and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 23 August 2022

About the service

Formby Manor Care Centre is a residential care home providing personal and nursing care to 51 people aged 65 and over at the time of the inspection. The service can support up to 76 people across three floors, each of which has separate adapted facilities. One of the floors specialises in providing care to people living with dementia and another floor supports people with nursing care.

People’s experience of using this service and what we found

Medicines were not always managed safely. The system for ordering, recording and administration was not effective, which placed people at unnecessary risk.

Systems to assess, monitor and improve the quality and safety of the service being provided were not always effective. Audits did not identify all the concerns we found at this inspection. Analysis and reviews of incidents that occurred in the home were not effective to ensure lessons were learned and used to improve safety.

Risks to people were assessed and appropriate plans were in place to keep people safe. However, some plans needed further details to guide staff in supporting people 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. However, we identified a concern with the recording of the mental capacity assessments. This was addressed during the inspection.

Relatives told us communication with the home was generally good and had improved in the last few months. However, some relatives felt communication between the staff could be improved to ensure concerns were handed over fully to better support people.

The home was well maintained and clean throughout. There were procedures in place to ensure visitors followed appropriate infection control procedures.

There were enough staff to meet people's needs. Staff told us improvements were being made at the home. Staff were positive about the support they received from the new manager, and from the provider.

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 21 May 2021).

Why we inspected

We received concerns in relation to the management of medicines, staffing levels and leadership in the home. 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 full report.

You can see what action we have asked the provider to take at the end of this report.

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 coronavirus and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Formby Manor Care Centre on our website at www.cqc.org.uk.

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 and will take further action if needed.

We have identified breaches in relation to the management of medicines and governance. 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.