Background to this inspection
Updated
14 July 2023
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
The inspection was carried out by 1 inspector and 1 nurse.
Service and service type
Needwood House is a ‘care home’. People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement dependent on their registration with us. Needwood House is a care home with 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.
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 (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with 3 people who used the service and 7 relatives about their experience of the care provided. We spoke with 11 members of staff including the registered manager, deputy manager, nurses, care workers, domestic staff, and the activities coordinator.
We reviewed a range of records. This included 4 people's care records and multiple people's medication and care monitoring records. We looked at 3 staff files and 3 agency staff profiles in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including audits and policies and procedures were reviewed. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
Updated
14 July 2023
About the service
Needwood house is a care home providing personal and nursing care to up to 33 people. The service provides support to older people, including people living with dementia, people with mental health concerns and younger adults. At the time of our inspection, there were 31 people using the service. Care was provided in one adapted building across two floors. There were communal rooms available on each floor, a conservatory, and an enclosed garden for people to enjoy.
People’s experience of using this service and what we found
Although governance systems were in place to keep people safe from harm, they had not identified some of the areas of improvement we found during this inspection; such as improvements required to the physical aspects of the home, additional training for staff, outdated care documentation and improvements to repositioning charts.
The provider acted quickly to the areas of improvement identified and took action to improve each area. These will be reviewed on the next inspection.
Risks to people were managed, assessed and mitigated appropriately. Accident and incident forms were investigated by the management team. Lessons learnt were shared with the staff team.
Staff were recruited safely and received supervision and regular training, including safeguarding training.
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.
People told us they felt safe with the care provided and with the carers supporting them. They said they received care from kind and compassionate staff members.
Relatives told us they felt their family members received a person-centred care, one which respected dignity and encouraged people to be independent.
People’s needs, choices and preferences were assessed and recorded in detailed care plans. This included people’s dietary needs and requirements. Health care professionals were consulted regularly, and staff followed their advice and recommendations.
Staff told us they felt supported by the registered manager and felt able to contribute and make suggestions to improve the quality of the care provided. Relatives told us they felt included in the service and felt confident to raise concerns.
The provider and staff worked in partnership with other health and social care agencies to deliver good outcomes for people and ensure their needs were met and reviewed.
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 the service under the previous provider was requires improvement, published on 30 April 2019.
Why we inspected
The inspection was prompted in part due to concerns received about a recent safeguarding concern, staffing, mental capacity assessments and unsafe care practices. A decision was made for us to inspect and examine those risks. We found no evidence during this inspection that people were at risk of harm from these concerns. Although, we did feel further improvements were required to the overall governance of the service. Please see the well led section of this full report.
The registered manager responded to all concerns raised and made improvements during the 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 COVID-19 and other infection outbreaks effectively.
The overall rating for the service is Good based on the findings of this inspection.
You can read the report from our last comprehensive inspection under the old provider, by selecting the ‘all reports’ link for Needwood House on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.