Lathbury Manor Care Home

Updated 14 April 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 completed by 2 inspectors.

Service and service type

Lathbury Manor 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. Lathbury Manor 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.

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 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 spoke with 3 people living in the service and 4 relatives about their experience of the care provided. We spoke with 12 members of staff including the home manager, deputy manager, catering staff, laundry staff and care staff.

We also 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.

We reviewed a range of records. This included 5 people’s care and medication records. We looked at 3 staff files in relation to recruitment and supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 14 April 2023

About the service

Lathbury Manor Care Home is a residential care home providing personal care for up to 29 people including people living with dementia. At the time of our inspection 26 people were using the service.

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

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 was one person using the service who had a learning disability and or who are autistic.

Systems and processes to ensure management oversight required embedding into practice. Improvement had been made to audits, however not all concerns had been identified prior to the inspection.

Improvements had been made to risk assessments to mitigate known risks to people. However, some environmental risks had not been identified or assessed. However, these were mitigated immediately after the inspection.

People received their medicines by trained staff. Medicine administration records recorded the reason why a person did not receive their medicine. However, one person had not received their medicine as prescribed.

Safeguarding procedures had been followed and people were protected from abuse. However, improvements were required to ensure records of injuries and potential causes of the injury were recorded.

We received mixed views on staffing levels. Relatives did not always feel there were enough staff on duty. However, staff told us they had enough staffing. During the inspection we observed that staff were not deployed sufficiently. For example, we observed people at risk of falls being left unattended in communal areas. However, the provider had assessed staffing levels by using a dependency tool.

People were supported by staff who knew them well. Relatives and people were involved in care planning. Staff shared information with relatives regarding incidents, concerns, or changes to the person’s needs.

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.

Staff felt supported in their role and enjoyed working at Lathbury Manor. Staff were positive about the management and felt valued and listened to.

The management team were committed to improving the service. They responded well to the feedback given and were open and transparent throughout the inspection.

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 06 January 2023) and there were breaches of regulation. 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. However, the provider remained in breach of regulation 17.

Why we inspected

The inspection was prompted in part by historical lack of notifications of incidents following which people using the service sustained injuries. These are subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of these incidents. However, the information shared with CQC about these incidents indicated potential concerns about the management of risk. This inspection examined those risks. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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.

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 not changed from requires improvement based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lathbury Manor on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to management oversight at this inspection.

Please see the action we have told the provider to take at the end of this report.

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.