Archived: Cumnor Hill House

Updated 8 June 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 team consisted of three inspectors and two Experts by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Cumnor Hill House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. 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. 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. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. This information helps support our inspections. We looked at notifications received from the provider. A notification is information about important events which the provider is required to tell us about by law. This ensured we were addressing any areas of concern. We looked at the service’s last inspection report. We used all of this information to plan our inspection.

During the inspection

We spoke with 11 people who used the service. Some people living in the home could not verbally give us feedback. As such we looked around the home and observed the way staff interacted with people. We looked at 10 people's care records and eight medicine administration records (MAR). We spoke with 17 members of staff including the area operations manager, the registered manager, the clinical lead, nurses, carers, the chef and domestic staff. We reviewed a range of records relating to people's care and the way the service was managed. These included staff training records, five staff recruitment files, quality assurance audits, incidents and accidents reports, complaints records, and records relating to the management of the service.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We received further feedback from four relatives and two healthcare professionals.

Updated 8 June 2022

About the service

Cumnor Hill is a residential care home providing personal and nursing care to up to 75 people. The service provides support to older people some of whom living with dementia. At the time of our inspection there were 56 people using the service.

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

People living at Cumnor Hill received safe care from skilled and knowledgeable staff. Staff knew how to identify and report any concerns. The provider had struggled to recruit permanent staff and were using a lot of agency staff which had impacted on the high standards of care people were used to. The provider had safe recruitment and selection processes in place.

People were supported with nutrition and hydration. However, the dining experience varied from unit to unit and could be improved. We saw staff deployment could be improved during mealtimes to ensure a better dining experience for people.

We found people’s records were not always up to date. The provider had already identified these shortfalls in their last audit and were working through an action plan. At the time of the inspection not all necessary actions identified had been completed so we could not be fully assured of the effectiveness of these actions.

Risks to people's safety and well-being were managed through a risk management process. There were sufficient staff deployed to meet people's needs.

Medicines were managed safely, and people received their medicines as prescribed. The provider had an electronic self-auditing system which allowed safe management of all aspects of medicines.

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.

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.

The home was well-led by a newly registered experienced manager who was committed to improving people's quality of life. The home had gone through constant changes in leadership which had impacted on staff support, people’s care and general management of the service. People, staff and relatives were positive about the new management team. The provider had effective quality assurance processes which were used to improve people’s care. The provider and registered manager had created and were working through an improvement plan following the recent audits. The service had a clear management and staffing structure in place and staff worked well as a team. Staff worked well with external social and health care professionals.

Rating at last inspection

The last rating for this service was outstanding (Published 27 June 2018)

Why we inspected

The inspection was prompted in part due to concerns received about staffing, recruitment, medicines management, records keeping, quality of care, staff knowledge of people’s needs and management of the home. A decision was made for us to inspect and examine those risks against all key questions.

We have found evidence that the provider needs to make improvements. For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The overall rating for the service has changed from outstanding to requires improvement based on the findings of this inspection.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.