22 September 2020
During an inspection looking at part of the service
Braceborough Hall Retirement Home is a care home providing personal and nursing care to 14 people aged 65 and over at the time of the inspection. The service can support up to 25 people. The service design is set out over two floors, with multiple communal areas and some shared room facilities.
People’s experience of using this service and what we found
The registered providers representative was unable to demonstrate formal systems and process to continually monitor and provide oversight to the service.
We recommended the provider representative follows through with plans to implement a formal quality assurance process to enable them to continually monitor and maintain oversight of the service.
The registered manager had effective processes in place to enable them to monitor quality, identify shortfalls in the service and address these in a timely way. People had care plans in place which were personalised to them. The service worked with health care professionals, who spoke highly of the care staff provide.
Risks associated with people’s care had been identified, assessed and were being monitored. Environmental risks had been mitigated to prevent harm to people. Staff received safeguarding training and understood their responsibilities to keep people safe. There were safe recruitment practices in place. Medicines were managed well. Action had been taken following accidents and incidents to reduce reoccurrence. Infection prevention and control had improved and there were clear processes to manage restrictions relating to the Covid-19 pandemic.
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 24 December 2019)
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 some improvements had been made and the provider was no longer in breach of regulation 9 (person centred care), regulation 12 (safe care and treatment) and regulation 17 (good governance).
Why we inspected
We carried out an unannounced comprehensive inspection of this service on 4 November 2019. Breaches of legal requirements were found. The registered manager completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, person centred care and good governance.
We undertook this focused inspection to check they had followed their action plan and to gain assurance around improvements in the service. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.
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 read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Braceborough Hall Retirement Home on our website at www.cqc.org.uk.
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.