12 January 2021
During a routine inspection
People’s experience of using this service and what we found
People were not always provided with safe care. There were some medicines that were not managed safely, however, we did not find anyone had been harmed by this. Staff were mostly issued with the correct personal protective equipment, though a small number of staff were not wearing the appropriate type of disposable headwear. The provider took steps to order this following our inspection.
People did not always have their needs re-assessed. That meant we could not be assured the care plans were up to date with the latest guidance for staff. Staff had yet to ensure people’s deprivation of liberty (DoLS) restrictions were applied for or updated, which meant we could not be confident peoples’ liberty was assured. Some people’s needs had not been fully planned for and training had not been put in place for those specific needs.
The service was not always well-led. Leadership and oversight of the service was poorly coordinated and records to support effective quality assurance of the service were not in place. Information in some documents was inconsistent.
Environmental risks were assessed and staff’s awareness to infection control had been heightened. Storage areas for equipment and chemicals had been identified and made more secure.
Staff were recruited safely and employed in sufficient numbers to care for the current people in the home. Staff were supported in their roles and training had been arranged for all staff. Supervisions, appraisals and team meetings were undertaken to ensure staff were informed of changes.
Relatives we spoke with had mixed opinions about the home in relation to communication from the new management team.
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
This is a first rating inspection.
Why we inspected
The inspection was prompted due to the provider request to use part of the home as a designated service. A decision was made for us to inspect and examine any risks.
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 the service can respond to coronavirus and other infection outbreaks effectively.
We have found evidence the provider needs to make improvements. Please see the safe and well led sections of this report for details.
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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to people’s safe care and treatment and poor governance. Please see the action we have told the provider to take at the end of this report.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.