Background to this inspection
Updated
9 August 2022
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 one inspector.
Service and service type
Ami Group 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. Ami Group 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 service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
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 sought feedback from the local authority who work with the service. We used the information the provider sent us in the provider information return (PIR). 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 with three people and five relatives about their experience of the service. We observed staff interactions with people in the communal areas. We spoke with seven members of staff including the registered manager, clinical lead, clinical area lead, training manager, general manager, senior carer and a carer.
We reviewed a range of records. This included seven people’s care plans and all the medication records. We looked at three staff files in relation to recruitment and a variety of records relating to the management of the service, including checks and audits.
Updated
9 August 2022
About the service
Ami Group is a residential care home comprising of The Knoll and Ami Court Units providing personal and nursing care to up to 67 people. The service provides support to adults who require nursing care. At the time of our inspection there were 64 people living at the service.
People’s experience of using this service and what we found
People told us they felt safe living at the service, relatives confirmed they thought their relatives were safe and safe knew how to support them.
The visiting protocols at the service had not always followed government guidance, not all people were given the option to receive visitors in their room. Before the inspection, people who could leave their room were required to see their visitors outside in sheds or a summerhouse. During the inspection, the registered manager contacted relatives to inform them they could visit in their loved one’s room. We confirmed with relatives after the inspection, they had been admitted to the service for their visits.
Practices within the service did not always promote good infection control or support people’s privacy. During the inspection, the podiatrist completed treatments in the communal lounge, where meals were served and surrounded by other people.
It is a legal requirement that a provider’s latest CQC inspection report rating is displayed at the service and website where a rating has been given. The provider had developed their first website but had not displayed the rating for the service. The provider told us they did not know they had to do this. During the inspection, the rating was put on the provider website.
There was enough staff to meet people’s needs who had been recruited safely. Potential risks to people’s health and welfare had been assessed and there was guidance in place for staff to reduce risks. Accidents and incidents had been recorded and analysed to identify patterns and trends, the action taken had been effective in reducing the risk of them happening again.
People received their medicines as prescribed, however, records were not always accurate. The registered manager had reported safeguarding concerns appropriately and staff knew when to report concerns.
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.
People had attended meetings to express their opinions of the service and make suggestions about activities and the menu, which had been acted on.
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 Good (published 18 December 2019).
Why we inspected
We received concerns in relation to visiting arrangements. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
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.
The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see the safe 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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ami Group on our website at www.cqc.org.uk.
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 monitor the service and will take further action if needed.
We have identified breaches in relation to Good Governance at this inspection. 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.