Withens Nursing Home

Updated 21 October 2021

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 Care Act 2014.

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

This inspection was carried out by one inspector.

Service and service type

Withens Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. However, this person left around the time of this inspection. This means the provider is legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection took place over two days, the first day was unannounced, the second was announced.

What we did before the inspection

We reviewed information we received about the service since the last inspection, this includes things the provider is legally required to notify us about. 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. This information helps support our inspections. We used all this information to plan our inspection.

During the inspection

We spoke with six people who used the service and four relatives about their experience of the care provided. We spoke with eleven members of staff including managers, nurses, care workers, activity staff, admin, chef and maintenance person.

We reviewed a range of records. This included four people’s care plans and multiple medicines records. We looked at four staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures, audits, action plans and meeting notes were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training and supervision data, some environmental risk assessments and fire safety reports.

Updated 21 October 2021

About the service

Withens Nursing Home is a residential care home providing personal and nursing care for up to 33 people. It can accommodate older people who have nursing needs and people living with dementia. At the time of the inspection there were 24 people living in the service. The service was arranged over two floors with communal areas on the ground floor. The upper floor was accessible via a lift.

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

People told us they felt safe in the service and liked living there. One person said, “I like it here, everyone is marvellous.” Relatives agreed their loved ones were safe in Withens. Staff received training in safeguarding, and this was up to date. People received safe care and treatment and environmental risks were managed. Medicines were managed safely in line with national guidance.

There were quality monitoring processes in place to monitor the service. There was a manager who was registered with the Care Quality Commission who had left around the same time as our inspection. The provider had already put interim management arrangements in place and a regional management team provided support for the service. Staff had confidence in the management team and found them approachable.

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

The last rating for this service was requires improvement (published 20 October 2020) and there were three 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 and the provider was no longer in breach of regulations.

Why we inspected

We received concerns in relation to safe care and treatment, poor care and needs, including nutritional needs, not being met due to low staffing. As a result, we undertook a focused inspection to review the key questions of safe and well led and a targeted inspection of one area in effective. We also checked that the provider had followed their action plan and to confirm they now met legal requirements.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

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 Withens Nursing Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.