Lady Spencer House

Updated 17 March 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

This inspection was carried out by two inspectors.

Service and service type

Lady Spencer House 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. Lady Spencer House 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. However, they were not currently based at the service. An acting manager based at the service reported directly to the registered manager, who maintained oversight and overall responsibility for the day to day running of the home. Following the inspection, the acting manager confirmed their intention to register as manager as well as the current registered manager.

Notice of inspection

This inspection was unannounced. Inspection activity started on 07 February 2023 and ended on 22 February 2023. We visited the service on 07 February 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from professionals who work with the service. We used the information the provider sent us 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 this information to plan our inspection.

During the inspection

We observed how the staff interacted with the people who used the service and looked at how people were supported throughout the day. We spoke with four people, the manager, three care staff, the activities coordinator and the chef. We looked at four people's care and support records and medicines records for nine people. We viewed records relating to the management of the service. These included recruitment and training records, quality audits, incident and accident records, the service improvement plan and the refurbishment plan. We also looked at a number of the provider’s policies. We spoke with four people’s relatives by telephone.

After the inspection

We held a teleconference meeting with the manager, the registered manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

Updated 17 March 2023

About the service

Lady Spencer House is a residential care home that provides personal care to up to 24 people. The service provides support to adults, some of whom were living with dementia. On the day of the inspection 23 people were using the service. The premises are an older style purpose-built building on three floors with communal space including a lounge and dining room on the ground floor and a further lounge on the first floor. Most bedrooms had a hand basin and there were shared bathroom facilities on each floor.

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

For the most part, people were protected from the risk of the spread of infection, although we found some items in people’s rooms required cleaning or replacement. We also found staff did not always use the correct bins to dispose of Personal Protective Equipment (PPE). Some bins were not lidded or emptied frequently enough. The manager took steps to address this straight away.

The provider continued to have a booking in system for visiting. This had not been reviewed to reflect the easing of the government restrictions on visiting imposed as a response to the COVID19 pandemic. Some relatives told us they did not like this because they felt it prevented them from seeing their family members as frequently as they would like.

There were enough staff on shift, and we saw that the manager had several ways with which they checked staffing numbers were sufficient such as a dependency tool, practice observations and whole shift observations.

Care plans and risk assessments were completed as required and regularly reviewed and updated. Everyone had a personal evacuation plan detailing the support they required to evacuate the building in the event of a fire. We saw that fire evacuation equipment was in place on all floors.

People told us they felt safe, and staff were aware of their responsibilities to protect people from harm. They understood who to report any concerns to both within the service and to external bodies. People’s medicines were managed safely, and we saw that appropriate referrals were made to external professionals to ensure people’s health care needs were met. People received appropriate support to maintain a healthy diet. We saw people had enough to eat and drink and that food provided appeared to be of a good quality. Where people were at risk of not eating or drinking enough, this was monitored, and appropriate referrals made.

Although some areas of the home and some furnishings were tired and in need of replacement at the time of the inspection, a refurbishment programme was underway. The manager assured us that people were being consulted about this work and that the needs of everyone, including those living with dementia, were being considered when making improvements to the environment.

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 that staff were kind, attentive, respected their decisions and protected their dignity and privacy.

People had a range of opportunities on offer to occupy their time in ways that were meaningful to them. This ranged from having access to newspapers, quizzes and word searches, to group and individual pastimes such as playing the guitar, making bread and popping to the shops. Staff engaged positively with people and there was an amiable and comfortable atmosphere in the home.

The provider and manager had good oversight of the service. There were robust quality monitoring systems which included seeking feedback from people, their relatives and staff through a variety of means. The manager was visible within the service and frequently carried out practice observations to review the quality of care provided. There was a strong emphasis on staff development and learning. Staff completed a wide range of training to support them to carry out their roles well. Incidents, accidents, events and complaints were all used to identify areas for development and improvement of the service.

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 26 June 2019) and there was a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

At our last inspection we recommended that the provider sought advice from the fire safety officer from Bedfordshire to ensure they had taken all reasonable steps to protect people from the risks associated with fire. At this inspection we found the service had sought this advice and had taken steps to improve fire safety at the service.

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

Why we inspected

This inspection was prompted by a review of the information we held 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.

Recommendations

We have made a recommendation that the provider reviews their policy in relation to visiting at the service to consider the most recent easing of government restrictions introduced during the COVID 19 pandemic.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.