16 November 2022
During an inspection looking at part of the service
Sovereign House is a nursing home providing personal and nursing care to up to 60 people across 3 different floors. The service provides support to adults, including people living with dementia. At the time of our inspection there were 34 people who lived at the home permanently and 18 people were staying at the home for a short period of assessment or rehabilitation following time spent in hospital.
People’s experience of using this service and what we found
Assessment of risk to people’s health and safety were not always robustly completed or mitigated. We found concerns regarding the lack of risk assessments and care plans for some people.
The management and administration of medicines was not always completed safely and maintenance of the home environment did not always promote effective infection control.
Staff supporting people living with dementia or communication difficulties required further training; however, there were enough suitable staff working at the home to support people's needs. People were safeguarded from the risk of abuse and the provider had systems and processes in place to respond to concerns.
The management team did not always have effective oversight of risk within the service. Clinical governance was not always completed to ensure staff had the training and competence to provide care and treatment safely.
People and staff were asked to provide feedback to obtain their views and experiences which was analysed and action plans put in place.
The registered manager and provider understood their legal duties and requirements and responded to risks identified within the service. The provider supported the management team to drive improvement in the home. The service worked with other health and social care professionals 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.
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 06 January 2022) and there were breaches of regulation. 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
The inspection was prompted in part due to concerns received about the management of continence products used at the service and the findings from the last inspection. 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.
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.
We have found evidence the provider needs to make improvements. Please see the safe and well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Sovereign House on our website at www.cqc.org.uk
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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account when it is necessary for us to do so.
We have identified continued breaches in relation to the assessment of risk, medicines management, infection prevention and control and the lack of management oversight at this inspection.
Please see the action we have told the provider to take at the end 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.