12 July 2023
During a routine inspection
People’s experience of using this service and what we found
People, relatives and staff felt the home had improved since the last inspection. The provider now had a more structured approach to quality assurance (QA); however a small number of audits hadn’t been completed consistently. Management reviewed the findings from audits, but the system needed a more in-depth analysis of findings to ensure lessons were learnt and shared. Particularly in relation to incidents, safeguarding concerns and complaints. Medicines were managed well, however records to support staff in their safe use required improvement. We have made a recommendation about this.
Opportunities for people, relatives and staff to share their views had improved. People and relatives gave positive feedback about the care provided. Staff felt morale, teamwork and the atmosphere in the home had improved.
There were enough staff to meet people’s needs and new staff were recruited safely. Some relatives felt there had been a lot of staff changes recently. Some staff interacted well with people but this was inconsistent, especially in one particular area of the home.
The home was clean and staff followed the provider's IPC practices. A new system had been implemented to deal with laundry to help prevent the spread of infections.
People were supported to have enough to eat and drink. Changes had been made to improve people’s dining experience.
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 this practice.
Opportunities for people, relatives and staff to share their views had improved.
The quality of people’s care plans had improved and were much more personalised. They included information about people’s preferences and what they were able to do for themselves.
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 17 December 2022). 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, however the provider continued to be in breach of regulation 17.
At our last inspection we recommended that the provider reviews how staff were deployed. At this inspection we found this had been completed and improvements made.
Enforcement
We have identified a continued breach in relation to medicines records.
Why we inspected
This inspection was prompted by a review of the information we held about this 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.
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.