Lace Hill Manor Care Home

Lace Hill Manor Care Home is a care home providing personal and nursing care to up to 62 people. At the time of our inspection there were 23 people living at the home. The building is purpose built and each person had their own room with en-suite facilities. Accommodation was spread over 2 floors. People had access to a wide range of seating areas throughout the home. People also had access to facilities including a cinema room, hairdressing salon, private dining room for hire and a café/bistro area.

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

Care plans were in place for each person. These had not always been kept up to date and were difficult to follow, as multiple records were in place. Records of fluid intake and repositioning did not consistently show staff had carried out the interventions at the required intervals.

There were systems to audit the service and we could see actions were taken to make improvements. However, we found the issues we identified during the inspection had not been picked up in audits.

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 found improvements were required in record keeping about decisions made in people’s best interests.

There were sufficient staff to meet people’s care needs. Pre-employment checks had been carried out to ensure staff had the necessary skills. People were protected from the risk of abuse. People we spoke with felt they or their relative were safe at the home. Any safeguarding concerns were reported to the local authority.

Risk assessments had been completed to reduce the likelihood of people being injured or harmed. People’s medicines were managed safely.

Staff followed good infection prevention and control practice. The home was clean and tidy throughout with good systems for managing laundry and adequate supplies of personal protective equipment.

Staff told us they felt supported and they completed numerous training courses. Training was updated during the course of the inspection.

People received a balanced diet and there was positive feedback about the quality of meals. We observed meals were unrushed and people were supported in a dignified manner.

People were cared for by staff who were caring, respectful and promoted their privacy, dignity and independence. Activities were available to provide stimulation and interest. We observed 1 activity where people enjoyed listening to a singer and some danced along to the music.

People were consulted about their care and asked for feedback in residents’ and relatives’ meetings.

People were supported to express their wishes regarding end of life care. The home had received numerous thank you cards from family or friends of people who had been cared for at the home.

People who provided feedback to us consistently said the registered manager was approachable and caring. Staff described the home as a good environment to work in and they felt listened to. The home offered its facilities to external organisations to use, to integrate the home with the local community.

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 12 April 2022 and this is the first inspection.

Why we inspected

This was a planned inspection for a newly registered 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 and Recommendations

We have identified a breach in relation to governance of the service. We have made recommendations regarding recruitment records, improving fire drills, assessing the suitability of the environment for people with dementia and care planning.

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.