Charnwood

Updated 26 February 2021

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 Care Act 2014.

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 one inspector.

Service and service type

Charnwood 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.

The service had an acting manager in post, they were not registered with the Care Quality Commission. Registered managers and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

We gave the service 24 hours’ notice of the inspection. This was because the service is small, and we wanted to be sure the manager would be at home to speak with us.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. 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. We took this into account when we inspected the service and made the judgements in this report.

During the inspection

We spoke with two people who used the service and two relatives about their experience of the care provided. We spoke with four members of staff including the manager, senior care workers, and care workers.

We reviewed a range of records. This included four people’s care records and multiple medication records. We looked at a variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at quality assurance records, training records and policies.

Updated 26 February 2021

About the service

Charnwood is a residential home providing personal and nursing care to 16 older people, some of whom were living with dementia at the time of the inspection. The service can support up to 19 people. Charnwood accommodates people in one adapted building over two floors.

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

People’s risk assessment and care plans sometimes lacked details on how they should be supported. Staff could however explain how people were kept safe and people and relatives told us they felt safe living at the home.

People were not consistently supported by enough staff. We have made a recommendation about staffing levels in the home. People were safeguarded from abuse as staff understood how to recognise and report any concerns. People received their medicines on time, and we were assured the home was following infection prevention procedures. Accident and incidents were reviewed, and lessons learned were shared with staff.

The governance arrangements were not consistently effective in driving improvements. Audits were in place and these were driving changes however this was not fully embedded, and more improvements were needed. The manager was notifying CQC as required of incidents which occurred. There was a system in place to learn when things went wrong and actions had been taken to make improvements following the last inspection and other professionals feedback.

People, staff and relatives spoke positively about the improvements and how the home was managed.

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 7 October 2020) and there were multiple breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been sustained and the provider was still in breach of some regulations.

The service remains rated requires improvement for the last three consecutive inspections.

Why we inspected

This inspection was carried out to check whether the Warning Notice we previously served in relation to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met

We had also received concerns in relation to infection prevention controls. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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 coronavirus and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained the same. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Charnwood 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 monitor the service required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified a continued breach in relation to governance of the home 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 for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.