Northleach Court Care Home with Nursing

Updated 28 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.

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

The inspection was carried out by two inspectors and an Expert by Experience. 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

Northleach Court Care Home with Nursing 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. Northleach Court Care Home with 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 reviewed their action plan. We sought feedback from the local authority and professionals who work with the service. We used the information in the provider information return (PIR) the provider sent us on the 26 January 2022. 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 to the registered manager, deputy manager and head of quality assurance. We spoke to 11 staff including the clinical lead, 2 nurses, 2 housekeepers, laundry assistant, 1 team leader, 1 senior carer, maintenance person, head chef and the admin officer for the service. We spoke to 6 people who use the service and 5 relatives of people who use the service.

We reviewed a range of care documentation, risk assessments and medicine records for people. We looked at staff recruitment files and documents around staff training and support. We reviewed a variety of records relating to the management of the service, including policies and procedures and quality assurance records.

We spoke to professionals who worked with the service to gain their feedback.

Updated 28 February 2023

About the service

Northleach Court Care Home with Nursing is a residential care home providing nursing and personal care for up to 40 people. The service provides support to older people, people with dementia and people with a physical disability. At the time of our inspection there were 26 people using the service.

At the time of inspection Northleach Court Care Home with Nursing was undergoing building work to expand and improve the premises.

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

Improvements had been made to the service following our last inspection. The environmental risks within the home were managed and reviewed to help keep people safe. People and staff told us they were excited about the improvements being made to the home and the provider had assessed the risk to people whilst the building work was being completed. Accidents, incidents and near misses were reported and responded to appropriately. This ensured the risk to people was reduced and there were systems in place to identify any changes in people’s risks.

People were supported in the management and administration of their medicines. As part of the inspection the provider was reviewing their processes around patch application for some people. Staff followed safe infection control practices and had access to personal protective equipment (PPE).

The provider was reviewing their recruitment policy to ensure a consistent approach when staff had worked both abroad and in the UK. Staff received induction, training and supervision to support them in their roles.

People felt safe living at the service and were protected from the risk of abuse or harm.

People’s needs and risks were assessed and regularly reviewed to reflect their changing needs. People’s risk management plans were detailed and individualised to each person.

Staff spoke passionately about their role in delivering good quality care to people in the service. People and their relatives felt staff were caring and kind.

The service adopted an open culture where good practice was celebrated and areas of improvement were shared and learned from.

The service had a number of systems in place to monitor the quality of care and safe running of the service.

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.

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 13 September 2021) and there was a breach in 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 and the provider was no longer in breach of regulations.

At our last inspection we recommended that the provider develops their processes to ensure their audits and other monitoring systems are able to effectively assess, monitor and mitigate risks to people. At this inspection we found the provider had acted on this recommendation and had made improvements.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 20 July 2021. Breach of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Northleach Court Care Home with Nursing on our website at www.cqc.org.uk.