Passmonds House

Updated 5 February 2022

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to care homes with outbreaks of COVID-19, we are conducting reviews to ensure that the Infection Prevention and Control (IPC) practice is safe and that services are compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

This inspection took place on 18 January 2022 and was announced. We gave the service 24 hours’ notice of the inspection.

Updated 5 February 2022

This was an unannounced inspection which took place on 03 and 04 December 2018.

We last inspected Passmonds House in March 2018 when we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations (2014). The service was in breach of Regulation 15 of the above act as we found concerns in relation to infection control, poor standards of hygiene and, maintenance of the premises. We issued a warning notice in respect of this breach, asking them to comply with the regulation by 17 August 2018. We also found that there were insufficient staff to meet the needs of the service, which was a breach of Regulation 18 of the Health and Social Care Act (2008) Regulations 2014. Following the inspection, the provider sent us an action plan which stated how the breaches would be addressed. This inspection was to check improvements had been made and to review the ratings. During this inspection, we found significant and major improvements had been made and the service was no longer in breach of the regulations.

Passmonds house is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Passmonds House provides accommodation and support for up to 33 people. Twenty-two of the rooms have en-suite facilities. The home is comprised of two units over two floors, with lift access to the upper floor and ramps to all entrances. At the time of our inspection there were 31 people living at Passmonds House.

A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.' At the time of our inspection the service had a manager who was in the process of registering with CQC.

Structural repairs and reorganisation of the basement area had been carried out to ensure that this area was safe and clean, and the registered manager had introduced more stringent measures to control and prevent the spread of infection. The housekeeping hours had been increased and a cleaning schedule had helped to improve the standards of hygiene and cleanliness of the service.

Care records showed that risks to people's health and well-being had been identified. These included specific risks, for example where a person’s behaviour could cause a risk to themselves or other people who used the service, and we saw that appropriate actions were recorded in care plans to minimise the risk of injury and followed up by staff. Environmental hazards had been assessed and where risks had been identified, appropriate measures were in place to minimise these risks. However, as we toured the building we found some cleaning and grooming items which could be harmful if used incorrectly had not been properly secured.

Staff understood how to keep people safe from harm, and the service had a safeguarding policy which helped to protect vulnerable people from abuse. Accidents and incidents were monitored and checked, and systems were in place to ensure that all medicines were stored correctly and managed by trained staff who were mindful when managing medicines to ensure that they were administered safely.

The service had good recruitment processes to ensure only suitable staff were employed. People told us that they were supported by staff who knew them well, and that there were enough staff to meet their needs. From looking at the training record and speaking with staff, we found some changes had been made since out last inspection to ensure staff were properly trained.

We saw staff worked well together and communicated effectively. They were attentive to any changes in people’s needs and passed on information to ensure continuity of care was provided. Written care notes were clear and gave a good indication of any interventions and interaction with the people who lived at Passmonds House.

Attention was paid to people’s diet and people were supported to eat and drink in a way that met their needs. Similarly, people told us that the staff were vigilant to their health care needs.

We saw that arrangements were in place to assess whether people were able to consent to care and treatment, and staff understood the need to obtain verbal consent from people using the service before a task or care was undertaken. Where people were subject to deprivation of liberty the appropriate authorisation had been sought.

We observed good caring interventions between the people who lived at Passmonds House and staff who worked there. It was clear staff understood not only what support people needed but also how they liked to be assisted. People were treated with kindness and patience and had been encouraged to form their own friendship groups.

Care plans were comprehensive but easy to understand. They were written in a person-centred way and reflected people’s needs, wishes and how they liked their care to be delivered. We saw that there were some activities available, and staff would spend time with people engaging in conversation or pastimes when they were able to.

People told us the registered manager was approachable and would listen and respond to any issues raised. She was supported by the service provider and area manager. The registered manager told us that the service had developed a good working relationship with the local quality assurance team, and when we spoke with them they told us that they had seen a big improvement in service delivery at Passmonds House.