Background to this inspection
Updated
15 July 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. In addition, an Expert by Experience supported the inspection by talking with people and relatives over the phone to gain their feedback. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Cheybassa Lodge 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. Cheybassa Lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
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. We used the information in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well and improvements they plan to make. We used all of this information to plan our inspection.
During the inspection
We spoke with five people who used the service and eight relatives about their experience of the care provided. We spoke with seven members of staff including the registered manager, care workers and a housekeeper. We reviewed a range of records. This included four people’s care records and medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
Updated
15 July 2022
About the service
Cheybassa Lodge is a residential care home providing personal care to up to 18 people. The service provides support to older people who live with dementia and physical frailty. At the time of our inspection there were 14 people using the service.
People’s experience of using this service and what we found
The provider’s quality assurance systems were not fully effective in identifying all concerns in the service. Some policies needed improvement, so they provided effective guidance to staff. We have made a recommendation about this. When the provider was made aware of any issues, they acted to address them and told us of their plans to further improve.
Although no restrictions were imposed on people and they were supported to have choice and control over their lives, the policies and procedures in place did not support this practice. We have made a recommendation about this.
People felt safe at Cheybassa Lodge and were protected from the risk of abuse. Risks associated with people’s health and support needs were safely managed. There were enough staff to meet people's needs in a timely manner. Safe procedures were in place to ensure people received their medicines as prescribed.
Staff received enough training to support people effectively and staff felt supported in their roles. People enjoyed their meals and had a choice about what they ate and drank. People's healthcare needs were met, and staff supported people to achieve good outcomes.
People spoke positively about the support they received and the staff team who cared for them. Staff were described as kind and caring. People were happy living at Cheybassa Lodge and relatives also provided us with positive feedback about the support people received. People’s privacy and dignity were respected.
People's care plans contained sufficient information to support staff to provide person-centred, responsive care to people. Staff recognised people's individual communication needs and provided meaningful activities for them.
The service had a positive person-centred culture. People, relatives and staff were positive about the registered manager. Everyone we asked said they would either recommend the service as a place to live or a place to work.
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 11 April 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 improvements had been made and the provider was no longer in breach of regulations.
The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections. We will describe what we will do about the repeat requires improvement in the follow up section below.
Why we inspected
The inspection was prompted in part due to concerns received about the application of Mental Capacity Act 2005. A decision was made for us to inspect and examine those risks.
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.
Recommendations
We have made recommendations for the provider to improve their practice into the application of the Mental Capacity Act 2005 and governance.
Follow up
We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.