Archived: Studley Bethesda Home

Updated 29 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 completed by two inspectors.

Service and service type

Studley Bethesda 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.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed the information we had received about this service since the last inspection, this included feedback from staff and statutory notifications. 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.

During the inspection-

We reviewed four care plans, medicines records, staff files and other documents relating to people’s care and the management of the service.

We spoke with one person living at the service, we also 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.

After the inspection

We continued to review documents relating to people’s care and management of the service away from the home. We spoke to seven members of staff including care staff and the registered manager. We spoke to two relatives of people living at the home.

Updated 29 October 2021

About the service

Studley Bethesda Home is a residential care home providing personal care to 7 people aged 65 and over at the time of the inspection. The service can support up to 13 people in one adapted building.

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

During this inspection, we identified breaches in relation to safe care and treatment, person centred care, safeguarding and good governance. We also made a recommendation about the management of some medicines.

People were not protected from risk of abuse. Unexplained injuries were not consistently investigated. Some staff felt that the registered manager did not take concerns raised about unexplained injuries seriously.

Risk to people was not always assessed and managed in a way that kept people safe from harm. The safety of the environment was not always considered as people’s needs became more complex. Accidents and incidents were not investigated robustly and actions to reduce future risk to people were not always implemented.

People received their medicines as prescribed, however medicines were not always stored safely.

We were not assured that staffing levels were sufficient to meet people’s needs overnight. Recruitment checks for staff were completed appropriately.

Care practices did not always promote people’s choice and dignity. We observed that some aspects of care in the home followed a task led approach rather than a person-centred approach.

Peoples changing needs were not always considered when supporting them with social and spiritual activities.

The staff team at the home were divided, some staff spoke of a closed culture which impacted people’s safety and wellbeing.

The registered manager did not always manage quality assurance and their regulatory responsibilities appropriately. Quality assurance systems had not identified the concerns we found as part of this inspection.

The service worked collaboratively with other healthcare professionals to promote good health outcomes for people. The registered manager managed complaints and compliments appropriately.

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 (14 March 2018).

Why we inspected

We received concerns in relation to risk management and support for people living with dementia. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well-led only.

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 good to Inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, responsive and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment, person centred care and good governance.

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

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.