7 June 2022
During a routine inspection
Cheybassa Lodge is a residential care home providing personal care to up to 18 people. The service provides support to older people who live with dementia and physical frailty. At the time of our inspection there were 14 people using the service.
People’s experience of using this service and what we found
The provider’s quality assurance systems were not fully effective in identifying all concerns in the service. Some policies needed improvement, so they provided effective guidance to staff. We have made a recommendation about this. When the provider was made aware of any issues, they acted to address them and told us of their plans to further improve.
Although no restrictions were imposed on people and they were supported to have choice and control over their lives, the policies and procedures in place did not support this practice. We have made a recommendation about this.
People felt safe at Cheybassa Lodge and were protected from the risk of abuse. Risks associated with people’s health and support needs were safely managed. There were enough staff to meet people's needs in a timely manner. Safe procedures were in place to ensure people received their medicines as prescribed.
Staff received enough training to support people effectively and staff felt supported in their roles. People enjoyed their meals and had a choice about what they ate and drank. People's healthcare needs were met, and staff supported people to achieve good outcomes.
People spoke positively about the support they received and the staff team who cared for them. Staff were described as kind and caring. People were happy living at Cheybassa Lodge and relatives also provided us with positive feedback about the support people received. People’s privacy and dignity were respected.
People's care plans contained sufficient information to support staff to provide person-centred, responsive care to people. Staff recognised people's individual communication needs and provided meaningful activities for them.
The service had a positive person-centred culture. People, relatives and staff were positive about the registered manager. Everyone we asked said they would either recommend the service as a place to live or a place to work.
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
The last rating for this service was requires improvement (published 11 April 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections. We will describe what we will do about the repeat requires improvement in the follow up section below.
Why we inspected
The inspection was prompted in part due to concerns received about the application of Mental Capacity Act 2005. A decision was made for us to inspect and examine those 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 that the service can respond to COVID-19 and other infection outbreaks effectively.
Recommendations
We have made recommendations for the provider to improve their practice into the application of the Mental Capacity Act 2005 and governance.
Follow up
We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.