Background to this inspection
Updated
14 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
The inspection was completed by 3 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
Cambridge Park Inpatient Unit 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. Cambridge Park Inpatient Unit is a 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. 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. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. We used all of this information to plan our inspection.
During the inspection
We spoke with 12 people who used the service and 4 relatives about their experience of the care provided. We spoke with 9 members of staff including the director of operations, registered manager, nurse, assistant practitioners, recovery workers, health care assistant, medication administrator, social worker and the maintenance team.
We reviewed a range of records. This included 6 people's care records and 9 medication administration records. We inspected 6 staff files in relation to their recruitment. A variety of other records relating to the management of the service, including audits and policies and procedures, were also reviewed.
We inspected the environment and spent time observing interactions between people and staff, and infection prevention and control practices.
Updated
14 March 2023
About the service
Cambridge Park Inpatient Unit is a care home registered to provide accommodation, personal and nursing care for up to 52 people who need short term rehabilitation and reablement support to return home or prevent hospital admission across 2 adapted areas within the grounds. At the time of our inspection, 36 people were residing at the service.
People’s experience of using this service and what we found
Information about risks and safety was not always comprehensive or up to date and full information about risks to people's safety was not always communicated to the staff.
Care plans were not always person centred. People and their families were not always involved in decisions about their care and treatment.
A system was in place to monitor the quality and safety of the service, however, this was not always effective in identifying and addressing issues.
Medicines management was not always in line with best practice guidance; medicine administration records were not always fully completed and guidance for staff not always in 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 did not always support this practice.
People had support from safely recruited staff. Staff received training in safeguarding and understood their role and responsibilities to protect people from abuse. The service had enough staff to keep people safe. We observed staff respecting people's privacy and dignity when providing care and support.
Staff had positive links with healthcare professionals which promoted people's wellbeing. Records confirmed the registered manager worked in partnership with stakeholders. We found the registered manager to be open and responsive to feedback. Visiting healthcare professionals told us that the management team and staff worked well with them.
Staff spoke positively about working for the provider. They felt well supported and could talk to the management team at any time, feeling confident any concerns would be acted on promptly. They felt valued and happy in their role.
The home was clean and tidy. Staff have access to and followed clear policies and procedures on infection, prevention and control that met current and relevant national guidance.
For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 30 July 2021). The service remains rated requires improvement.
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 the provider remained in breach of regulations.
At our last inspection we recommended that the provider reviewed their staffing levels and sought guidance to improve staff training and supervision systems. At this inspection we found the provider had made improvements in these areas.
Why we inspected
We carried out an unannounced inspection of this service on 29 June 2021. Breaches 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, medicine management, person centred care and good governance.
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, effective, responsive and well-led.
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 remained requires improvement.
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Cambridge Park Inpatient Unit on our website at www.cqc.org.uk.
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.
Enforcement and Recommendations
We have identified breaches in relation to medicine management, risk management, person centred care and good governance at this inspection. We have also made a recommendation in relation care planning systems and the mental capacity records.
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.