Calder View

Updated 12 November 2022

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 Health and Social Care Act 2008.

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

This inspection was carried out by two inspectors.

Service and service type

Calder View is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Calder View is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced. Inspection activity started on 29 September 2022 and ended on 04 October 2022 when we provided feedback remotely. We visited the location’s office/service on 29 September 2022.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. The provider did not complete the required PIR. This is information providers are required to send us annually with key information about the service, what it does well and improvements they plan to make. Please see the well-led section of this report for further details. We used all this information to plan our inspection.

During the inspection

We spoke with 2 people who used the service and 1 relative about their experience of the care provided. We spoke with 5 members of staff including the registered manager, 3 care workers and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. During the inspection, we visited both floors of the home and we reviewed a range of records. This included reviewing 2 people's care records in detail. During the inspection we also looked at various medicines records and the storage of medicines. We looked at 2 staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were also reviewed.

Updated 12 November 2022

About the service

Calder View is a residential care home providing personal care to up to 6 people. The service accommodates people who require support with their mental health. At the time of our inspection there were 6 people using the service, who resided in one building which had 2 floors.

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

Staffing levels were lower than required on some shifts. The service was in the process of recruiting a new staff member to address this. Recruitment processes needed improving to ensure full employment history was being sought. We made a recommendation about this. Medication pill counts matched records, but some paperwork relating to medicines needed to be put in place, guidelines needed to be followed and medicines audits needed to be more robust. We made a recommendation about this. Although the home was clean and tidy and people were supported to have visitors, on arrival staff were not appropriately wearing face masks, as the provider’s policy did not align with national guidance. This was immediately rectified. We made a recommendation about this. Systems and processes were in place to safeguard people from abuse, however we found one example where necessary referrals had not been made. We were able to review some examples of lessons learned and there were appropriate risk assessments in place.

Quality assurance systems required some improvement, the medicines audits did not identify all of the concerns we found and the provider had not completed the provider information return (PIR) when requested. The registered manager spoke about being open and honest when things went wrong, however we did find one incident that had not been appropriately reported, this was before the registered manager’s time in post. We received positive feedback about the registered manager and staff knew how to escalate concerns if necessary. Staff worked in partnership with various agencies and the service engaged with people and their relatives to help drive improvement.

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.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

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 18 July 2018).

Why we inspected

We made a decision to inspect Calder View after completing a full review of information we hold about this service. 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 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. The overall rating for the service has changed to requires improvement. 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 Calder View on our website at www.cqc.org.uk.

Enforcement and Recommendations

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 and will take further action if needed.

We have identified breaches in relation to governance at this inspection. We have also made recommendations in relation to medicines, recruitment practices and infection control practices.

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.