About the service Savernake View Care Home is a care home providing nursing and personal care for up to 64 people. The service provides support to older people, people under 65 years and people living with dementia. At the time of our inspection there were 48 people using the service.
People had their own rooms on two floors with en-suite bathrooms. There were various communal areas available to people around the home including a cinema, café, hair salon, lounges, dining rooms and a private dining area. There were well established gardens available from the ground floor.
People’s experience of using this service and what we found
Systems in place to manage and respond to incidents were not robust. Staff were not consistently recording incidents on the correct forms which meant management were not aware of some safeguarding incidents or injuries. Whilst staff had sought medical advice in response to accidents and incidents, we found incidents had not been reported to the local authority or notified to CQC in all cases. In addition, we were not able to see action taken to prevent reoccurrence or monitoring for trends. The provider took immediate action to address this shortfall during our inspection.
Risks had been identified and assessed but risk management plans did not always provide staff with the guidance needed to support people safely. People who experienced distress reactions did not have guidance in place for staff to know how to respond to their distress consistently. Safeguarding incidents involving people were not added to handover sheets. This meant staff would not be aware of who was experiencing distress. This was a particular concern due to the high numbers of agency staff used.
Monitoring records in place to record actions taken in response to risks were not clear. We shared this with the registered manager during our inspection. They told us they would make sure agency staff followed the same recording processes as permanent staff.
Medicines were managed safely. An electronic medicines system was in use which helped to make sure people had their medicines as prescribed. 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 service was clean, and the property was kept in good repair. External contractors were used to service facilities and records were kept demonstrating safety. Staff wore personal protective equipment appropriately and there was plenty of stock available.
People could have visits from friends and families when they wished. During our inspection we observed visitors being welcomed all around the home. People told us they felt safe at the service and appreciated the staff and management. People could share their views in meetings which were held regularly.
Staff were recruited safely and there were sufficient numbers of staff deployed. At times there were staffing challenges due to short notice sickness, but the management tried to cover gaps with agency staff. In order to provide continuity agency staff were booked in advance which meant they booked the same staff to work at the service.
Since the last inspection there was a new registered manager. Feedback about their approach was positive. Staff told us they were approachable and supportive. People told us they knew who the registered manager was and felt able to share ideas or concerns with them.
Whilst quality monitoring systems in place had identified areas for improvement, they had not identified shortfalls found at this inspection. Medicines audits were taking place and being monitored by the provider. Infection prevention and control audits were completed regularly to monitor for cleanliness and good hygiene practice.
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 2 August 2021). 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 the provider remained in breach of regulations.
Why we inspected
We received concerns in relation to staffing and high use of agency staff. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. 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 remained requires improvement based on the findings of this inspection. You can see what action we have asked the provider to take at the end of this full report.
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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Savernake View Care Home on our website at www.cqc.org.uk.
Enforcement and Recommendations
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 identified a breach in relation to governance systems,
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
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.