Santa Care

Updated 25 November 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 one inspector.

Service and service type

Santa Care 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. Santa Care is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the 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 two people who used the service and observed care and support. We spoke with the support worker on duty. The registered manager and deputy were unable to attend the inspection. We viewed the care records for all three people and three staff files that included recruitment, supervision, appraisal and training records. We also looked at medicines management for all three people and records relating to the management of the service including service checks and audits.

Following the inspection, we tried to obtain feedback from relatives but were unsuccessful. We received feedback from two staff members. We contacted two healthcare professionals by email but did not receive a reply. We looked at a range of documents sent to us such as audits, risk assessments, meeting minutes and care records.

Updated 25 November 2022

About the service

Santa Care Home is a care home providing accommodation and personal care for up to four adults with learning disabilities or mental health needs. At the time of the inspection, three people with mental health needs were using the service.

At the time of the inspection, the location did not care or support for anyone with a learning disability or an autistic person. However, we assessed the care provision under Right Support, Right Care, Right Culture, as it is registered as a specialist service for this population group.

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

Right care

Systems to protect people from the risk of infection were not always effective. We found that, apart from the kitchen, the home required deep cleaning and repair.

There were systems to manage risk and keep people safe. However, these had failed to identify some safety issues. Risk assessments were in place, but these were not always reviewed and updated.

There were systems in place to monitor the quality of the service but these were not always effective as they had failed to identify where improvements were needed.

Medicines were managed safely and people who used the service received these as prescribed.

There were enough staff to support people and meet their needs. Staff were recruited appropriately, and all checks were in place. Staff received an induction, training and supervision and felt supported in their roles.

Right support

People who used the service did not always receive the right support and were not always supported in a person-centred way and given choices. People were not always supported to maintain their independence.

People’s healthcare and nutritional needs were met. People were supported to access healthcare professionals and to attend appointments as needed.

People's needs were assessed before they started using the service and care plans were developed from initial assessments. People and those important to them were involved in reviewing care plans.

Right culture

The registered manager and senior staff were responsive to and worked in partnership with other agencies to meet people’s needs.

Staff told us they were happy and felt well supported. They enjoyed their work and spoke positively about the people they cared for. They received the training, support and information they needed to provide effective care. The provider had procedures for recruiting and inducting staff to help ensure only suitable staff were employed.

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 13 February 2018). The rating for the service had changed to requires improvement.

Why we inspected

We carried out this inspection based on the date of the last inspection.

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.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

Enforcement and Recommendations

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 safe care and treatment, person-centred care and good governance at this inspection.

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.