Hebburn Manor

Updated 18 October 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 Act.

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 one inspector, a specialist nurse advisor 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.

Service and service type

Hebburn 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.

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. The new manager had applied to be registered.

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. 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 used all of this information to plan our inspection.

During the inspection

We spoke with five people, two visiting healthcare professional and nine staff, including the manager, regional manager, director, care and domestic staff. We spoke with seven relatives over the telephone and contacted five more staff via email.

We observed interactions between staff and people in communal areas, including at lunchtime. We reviewed a range of records. This included five people's care records and medication records. We looked at two staff files. A variety of records relating to the management of the service, including policies and procedures, were reviewed. We contacted three further health and social care professionals via email.

Updated 18 October 2022

About the service

Hebburn Manor is a residential care home providing personal and nursing care to up to 60 people aged 65 and over, and adults under 65, including people living with dementia. At the time of inspection there were 51 people using the service.

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

Auditing and oversight arrangements had not identified and rectified areas that needed improvement, such as person-centred care planning and medicines administration recording. Records were not always accurate or legible.

There were occasions when there not enough staff to meet people’s needs promptly. Staff deployment at mealtimes was not well planned, meaning people had to wait for their meals.

People’s basic care needs were met by staff, who worked hard to respond to nurse calls and other requests for help.

Medicines were stored safely. Record keeping and oversight of medicines administration required improvement.

People felt safe and regularly saw their relatives. Some staff knew people and their needs extremely well. There was a reliance on agency staff, meaning some staff did not always know people’s needs well. The new manager had plans in place to reduce the use of agency staff.

Risks to people's health and safety were assessed and documented in care planning. Staff followed these plans to ensure people’s safety.

The provider had safeguarding and whistleblowing policies and systems in place. Staff understood these and how to identify potential signs of abuse.

Senior care staff worked well with external partners to keep people safe. There was mixed feedback from external professionals about how well staff communicated with them and sought and acted on advice.

The manager and regional manager had a clear vision for how they wanted to improve the service. They had begun to make progress against a comprehensive action plan. They were responsive to feedback.

The environment was clean and there had been significant refurbishment to improve it, particularly on the ground floor.

Staff were recruited safely. They received an initial induction and ongoing training and support.

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’s nutritional needs were understood and acted on. Staff used nationally recognised tools to monitor risks associated with malnutrition.

Staff interacted patiently with people throughout the inspection.

The number and variety of activities had reduced in recent months due to unforeseen staff absence. The new manager had prioritised plans to increase the amount and variety of activities available. They also planned to make new community links and involve relatives more.

Staff felt they could approach the new manager with concerns or problems. External professionals who had interactions with the new manager provider positive feedback regarding their openness and proactive approach.

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 14 October 2021 and this is the first inspection.

The last rating for the service, under the previous provider, was requires improvement, published on 1 December 2021.

Why we inspected

This inspection was prompted by a review of the information we held about this service. We have found evidence that the provider needs to make improvements. Please see all key question sections of this full report.

Recommendations

We have made a recommendation about staff deployment at mealtimes and the provider's dependency levels.

We have made a recommendation about medicines auditing and oversight.

Follow up

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.