The Withins

Updated 3 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 completed by an inspector, medicines inspector and a specialist nurse advisor.

Service and service type

The Withins 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. The Withins 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 already held and had received about the service since the time of the last inspection. We sought feedback from the local authority and other professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 6 people. We observed people’s care and staff interaction with them. We spoke with the registered manager, newly appointed manager, 1 team leader, 1 support worker, 1 activities coordinator and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records. This included multiple people’s care records, personnel files and medicines administration records. A variety of records relating to the management of the service, including policies and procedures were also reviewed. We wrote to the registered manager, new manager and nominated individual after the site visit and requested some information. We received multiple additional documents and written explanations.

Updated 3 February 2023

About the service

The Withins is a residential care home providing personal care for up to 17 people. The service provides support to people with a diagnosed mental health condition to provide rehabilitation support. At the time of our inspection there were 11 people using the service.

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

Oversight of training required for staff had improved. However, staff who had previously undertaken a vast number of online training courses in one day had still not refreshed this training. Furthermore, bespoke training on how to support people with mental health needs had not yet been provided to staff. An updated training plan was in place to ensure this would be provided to staff soon.

Although we found leadership and the general oversight of the service had improved. Audits continued to not be completed consistently. A robust governance framework had not yet been established.

The service outlined in their statement of purpose they would support people with a focus upon health promotion and rehabilitation. Although there were future plans in place to introduce a bespoke recovery model at the service, work in this area had not progressed since our last inspection.

Oversight of accidents and incidents had improved. But there was still a missed opportunity to complete analysis of incidents to establish if patterns or themes were emerging, in order to prevent or minimise reoccurrence of incidents.

Oversight of people’s medicines had improved, and people received their medicines in a person-centred and unhurried manner. However, we found there was still areas some areas of improvement required.

Since the last inspection, numerous changes were made to ensure people received safe care. People’s risk assessments and care plans were replaced, updated and made more individualised.

Risks connected to the safety of the premises improved and significant work was completed to ensure the service met the fire safety concerns identified. Potential ligature risks were assessed and made safe.

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 were recruited safely and there were enough staff to safely meet people's assessed needs. Staff told us they felt supported in their roles and felt the recent change in management had implemented positive changes.

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 inadequate (published 25 August 2022).

This service has been in Special Measures since 25 August 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Withins 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 continued breaches in relation to staff training and good governance. Please see the action we have told the provider to take at the end of this report.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

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