Culverhayes Nursing Home

Updated 23 December 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.

Inspection team

The inspection team consisted of two inspectors on-site. We used an Expert by Experience to make phone-calls to relatives following the site-visit. 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

Culverhayes Nursing Home 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. Culverhayes Nursing Home is a care home providing 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. The registered manager was temporarily absent from the service, so the service was being led by an interim manager.

Notice of inspection

The inspection was unannounced.

What we did before the inspection

We used information we had received about the service since the last inspection. 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 2 people that use the service, 5 relatives, 4 staff and the interim manager. We 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. We reviewed a range of records. This included people’s care plans, daily records, recruitment files, medication records, complaints and audits.

Updated 23 December 2023

About the service

Culverhayes Nursing Home is a residential care home providing the regulated activities personal and nursing care to up to 65 people. The service provides support to older and younger adults, people with dementia and mental health needs. At the time of our inspection there were 62 people using the service.

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

People were supported safely. Staff had a good understanding of safeguarding and acted in people's best interest where necessary. People had clear guidance in their care plans and staff followed this to keep people safe.

Staff were recruited safely. There were enough staff to enable people to receive person-centred care. There were various types of activities available, including trips out and a combination of indoor activities, so people could choose which they would prefer.

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.

There was a clear staffing structure within the service and staff were clear about their roles and responsibilities. Staff told us they worked well together using a “whole team approach." The service worked well with external health care professionals, and we saw referrals were made to specialist care services where appropriate.

Staff spoke highly of the leadership of the service; and described it as “10 out of 10.” Staff told us there were opportunities for professional development. We received mostly positive feedback from relatives.

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 5 June 2023).

At the last inspection we recommended the provider review and monitor the management, auditing, and oversight of medicines, to ensure shortfalls, errors and omissions are consistently identified. We found the provider had made improvements at this inspection.

Why we inspected

The inspection was prompted due to concerns received about personal care and pressure area care. We were also informed of an allegation of physical abuse and neglect. A decision was made for us to inspect and examine those risks.

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 found no evidence during this inspection that people were at risk of harm from these concerns. Please see the safe and well led sections of this full report.

Follow Up

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