Background to this inspection
Updated
17 February 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.
Inspection team
The inspection was undertaken by 2 inspectors on both days of the inspection and an Expert by Experience on the first day. 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
Feng Shui House (Blackburn) 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. Feng Shui House (Blackburn) is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a provider registered with the Care Quality Commission. This means that they are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
The first day of inspection was unannounced.
What we did before inspection
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 reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. We used all this information to plan our inspection.
During the inspection
We spoke with 4 people who used the service about their experience of the care provided. We spoke with 7 staff including; the provider, manager, support manager, the cook and care workers. We also spent time in communal areas observing how staff supported people.
We reviewed a range of records. These included care records, records relating to medicines, staff recruitment, training and supervision, building maintenance, cleaning and equipment checks, accident and incidents and safeguarding logs and policies and procedures for infection control. A variety of records relating to the management of the service, including audits and policies and procedures were reviewed.
Updated
17 February 2023
About the service
Feng Shui House (Blackburn) is a residential care home providing accommodation and personal care to up to 16 people in one adapted building. At the time of our inspection there were 15 people using the service.
People’s experience of using this service and what we found
There were not always sufficient staff deployed to meet people's needs. People did not receive the support they required in a timely manner. Improvements had been made to the building, furnishings and decorations. The required health and safety servicing and certification had taken place, but checks undertaken by managers and the provider had not identified shortfalls found during the inspection. These included; dirty and untidy laundry, unsafe storage of combustible materials, risks to people’s health and safety in relation to blocking of the means of escape in case of fire, and hazardous substances being accessible to people who used the service. People’s dignity and privacy was not always respected or promoted. Further improvement was needed to systems for auditing, assessing, monitoring and improving the quality and safety of the service.
We have made recommendations about ensuring training records are accurate and ensuring appropriate activities are taking place.
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. Records indicated that people's consent to care and support was sought. Care records showed people, and where appropriate their representatives, had been involved in decisions about their care. Where appropriate those with legal authority were involved in decisions.
There were safe systems of recruitment in place. Person centred risk management plans were in place to guide staff on the action to take to mitigate risks and records. Communal areas and bedrooms were clean and tidy.
Staff told us they felt supported and they received supervision. People were supported with their health care needs. People’s nutritional needs were met and people were positive about the food.
Staff and manager’s we spoke with knew people well. They spoke in kind and caring terms about the people they supported.
Care records were person centred and gave sufficient information to guide staff on the support people needed and how support should be provided. There was a system for managing complaints. People told us they could raise any concerns.
Prior to our inspection the provider had identified some shortfalls and had employed a support manager temporarily to help with the required improvements. The support manager and manager were very honest, open and responsive during our inspection. They took immediate action to resolve concerns. People told us the manager was approachable. Policies and procedures were available to guide staff on what was expected of them in their roles.
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 7 April 2022) and there were breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve.
This service has been rated requires improvement for the last 2 consecutive inspections.
Why we inspected
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.
This inspection was carried out to follow up on action we told the provider to take at the last inspection.
Enforcement and Recommendations
We have identified breaches in relation to staffing, health and safety, dignity and respect and governance at this inspection. We have also made 2 recommendations.
Please see the action we have told the provider to take at the end of this report.
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.
The overall rating for this service is ‘requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'inadequate' in any Key Question over 2 consecutive inspections. The ‘inadequate’ rating does not need to be in the same question at each of these inspections for us to place services 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, 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.