20 June 2022
During an inspection looking at part of the service
Winterbourne Steepleton- Steepleton Manor is a residential care home providing nursing and personal care to up to 32 people. The service provides support to predominately older people. At the time of our inspection there were 19 people using the service.
People’s experience of using this service and what we found
Some people could not be consistently confident that the risks they faced would be assessed, mitigated and monitored.
Overall, people’s medicine management was safe. However, improvements were needed to the safety of unwanted medicines waiting for collection.
Risks relating to infection prevention and control (IPC), including in relation to the COVID-19 pandemic were assessed and managed. Overall, staff followed recommended IPC practices with some minor areas for improvement. Safe visiting was supported.
There was a poor understanding of The Mental capacity Act 2005 and this meant people were not consistently supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests. Actions were taken following the inspection visit to make sure any restrictive practices were reviewed with people and or their representatives.
People’s needs were assessed. However, their emotional and social wellbeing needs were not consistently planned for or were consistently delivered in a person-centred way.
The governance systems were not entirely effective and had not identified the shortfalls found at this inspection.
The registered provider and manager took actions in response to our feedback and findings. However, we were not able to assess the impact of these actions on people’s experiences at this inspection.
People felt safe and were comfortable and relaxed with staff who supported them. Relatives told us they felt their family members were safe and overall were well cared for. Throughout the inspection we saw relaxed, kind and caring interactions between staff and people. People received good quality nursing care.
Overall, there were enough staff to meet people's needs but some people experienced some delays in support at mealtimes. There was a staff team who knew people well and they were recruited safely.
There was an open, improving and positive culture within the home and people, staff and a relative told us the manager and staff team were approachable and helpful.
For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk
Rating at last inspection:
The last rating for this service was good (10 March 2018).
Why we inspected
This inspection was prompted by a review of the information we held about this service.
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 to requires improvement following this 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.
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 found breaches in relation to risk management, understanding of the MCA and governance at this inspection.
Please see the action we have told the provider to take at the end of the full version 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.