Stinchcombe Manor

Updated 18 May 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

Two Inspectors carried out the inspection.

Service and service type

Stinchcombe 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. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The Registered Manager

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.

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 considered the feedback from the local authority and professionals who work with the service. We used the information the provider sent us in September 2022 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 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 spoke with 7 people who lived at Stinchcombe Manor and with 1 person’s relative about their experience of the care and support provided by the service.

We spoke with 9 staff including the registered manager, 2 senior support staff, 3 support workers, 1 chef, 1 maintenance worker and 1 housekeeper.

We reviewed a range of records. This included 6 people's care records. A variety of records relating to the management of the service, including policies and procedures were also reviewed.

We continued to seek clarification from the management team to validate evidence found. We sought and received feedback from 3 healthcare professionals involved with the service as well as local authority commissioners.

Updated 18 May 2023

About the service

Stinchcombe Manor is a care home providing accommodation to persons who require nursing or personal care, for up to 19 people. The service provides support to people living with mental health and associated needs. At the time of our inspection there were 12 people using the service. Some people living at Stinchcombe Manor requires support when they become anxious or distressed.

Stinchcombe Manor is a large adapted home with a number of communal areas people can access, including two lounges, a dining room and garden.

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

The registered manager did not always operate effective systems to identify, assess the safety of the home to enable them to take action. The provider’s governance systems had not always identified or taken action in relation to concerns we found at this inspection.

People's care needs had not always been recorded in full. The registered manager was aware of this; however, action had not been taken from audits carried out in February 2023. Checks of people's environments were routinely carried out, however these hadn't always comprehensively identified potential shortfalls.

People spoke positively about Stinchcombe Manor and enjoyed the time they spend with support workers. On both days of the inspection people were enjoying games and activities with staff. Staff spoke positively about working at Stinchcombe Manor and the support they received to provide person centred care.

People's medicines were managed effectively, and people were protected from the risk of infection.

People's individual risks were known by support workers. Staff had clear guidance to support people when they became anxious. Where incidents and accidents occurred, the registered manager had systems in place to ensure appropriate action was taken to reduce the risk of avoidable harm.

The registered manager ensured the views of support workers and people were listened to and acted upon. Staff spoke positively about the communication they received and discussed the improvements happening at Stinchcombe Manor.

Deprivation of liberty safeguards had been applied for when people could not consent to live in the care home.

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 were people using the service who have a learning disability and or who are autistic.

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 Good (published 23 July 2022). At this inspection the rating has remained the same.

Why we inspected

This inspection was prompted by a review of the information we held about this service, including information of concern in relation to people’s care and the management of the service. We also had received concerns about an incident which occurred at Stinchcombe Manor. This incident was 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 the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of the environment. This inspection examined those risks.

As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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.

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

Enforcement

We have identified a breach in relation to good governance at this inspection. 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.