21 July 2020
During an inspection looking at part of the service
Windsor Park Nursing Home is a care home registered to provide personal care for up to 19 people who have nursing care needs, including people living with dementia. At the time of our inspection, there were 14 people living at the service. Accommodation was provided over two floors and a passenger lift was available.
People's experience of using this service and what we found
People were at risk of harm. Risks associated with people's care and treatment needs, including how clinical needs were assessed, monitored and managed were of significant concern. Guidance for staff about how to meet people's individual care and treatment needs either lacked detail or was not available for staff.
Clinical leadership and oversight at the service was insufficient as a result of both the registered manager and clinical lead being away from the service for prolonged periods due to the Covid-19 pandemic. The new director of the provider company and nominated individual had only recently taken over management of the service. There was some evidence of clinical supervision and competency assessments of nursing staff, however, these were not always documented sufficiently. This impacted on people receiving safe care and treatment.
There were no systems or processes in place to review incidents or any analysis completed that may have identified any themes or patterns to reduce reoccurrence. A failure to take action to learn from incidents impacted on people’s safety.
People’s dependency needs had not been assessed since 2019. This meant it was difficult to establish if staffing levels were sufficient to meet people’s individual needs and safety.
Staff lacked specific training in some areas, impacting on people’s care needs being fully known, understood or effectively met by staff at the service. Safe staff recruitment and induction procedures had not always been completed, exposing people to potential harm.
The procedures for staff to exchange information about people’s care and treatment needs was not safe or effective.
The environment, including furnishings were worn and needing redecoration and refurbishment. The Provider identified this issue within their action plan and planned to refurbish the home within the next six -twelve months. Infection prevention and control procedures reflected the Covid-19 pandemic guidance. People received their prescribed medicines when they needed them.
Systems and processes to assess and monitor quality including health and safety had not been fully kept up to date. This included audits and checks in relation to medicines, care plans and risk assessments.
Following the inspection, the provider sent us an action plan based upon the main issues found at this inspection. The impact of the planned actions will be assessed at our next inspection.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was Good (Published 28 December 2018). The rating for the service has changed from Good to Inadequate. This is based on the findings at this inspection.
Why we inspected
We received concerns in relation to the management, oversight and governance of the service, including staffing and clinical competency. Many of these issues had occurred as a result of the Covid-19 pandemic. We raised these concerns pre-inspection with the provider, but were not sufficiently assured. As a result, we undertook a focused inspection to review the key questions of 'Safe' and 'Well-led' only
We received concerns in relation to the management, oversight and governance of the service, including staffing and clinical competency. We raised these concerns pre-inspection with the provider, but were not sufficiently assured. 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.
We have found evidence that 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 report.
Enforcement
We have identified two breaches in relation to safe care and treatment and good governance.
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
The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.