Stradbroke Court

Updated 28 October 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 undertaken by 3 inspectors and an Expert by Experience. 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

Stradbroke Court 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. Stradbroke Court 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. The registered manager was on leave during our inspection and a temporary manager was in place. We will refer to them as the ‘manager’.

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 and professionals 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 6 people who used the service and 6 relatives. We observed the interactions between staff and people using the service. We reviewed the care records of 7 people who used the service and multiple medicines records.

We spoke with 8 members of staff including the manager, care operations manager, deputy manager, trainee deputy manager, care assistants, senior staff and housekeeping staff.

We also reviewed records relating to the governance of the service, including incidents and accidents, 3 staff records relating to recruitment, training records and audits.

After the inspection visit, we received feedback from the services’ administrator, and 1 healthcare professional. we spoke with the local authority safeguarding team, the provider’s care director, and a further 7 relatives for their views on the service.

Updated 28 October 2023

About the service

Stradbroke Court is a residential care home providing accommodation and personal care to up to 43 people in an adapted building across 5 units. The service provides support to older people, some living with dementia and mental health conditions. At the time of our inspection there were 34 people using the service.

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

Improvements were needed to ensure people always received good quality, compassionate, individualised and safe care as a minimum standard.

Risks to people were not always robustly assessed and mitigated. Staff did not always have the information they needed to provide safe care because risks associated with people's care had not always been fully assessed. This included risks relating to falls, diabetes, and choking.

There were not sufficient numbers of suitably skilled staff to make sure they could meet people's care and support needs; there had been a high number of unwitnessed falls in the service. Staffing levels were increased following the inspection.

Actions to detect, investigate and report allegations of abuse or neglect were not always sufficient. The local authority had received a high number of safeguarding referrals, which included concerns around people's sexual safety.

Infection control procedures required improvement. We found personal protective equipment (PPE) stored next to toilets, which posed a risk of cross contamination. The service was in significant need of redecoration. Paintwork was chipped in many areas and carpeting was worn. This meant that effective cleaning could not take place.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. Further work is needed to ensure mental capacity assessments and best interest decisions are in place for all aspects of people's day to day care.

People were referred to relevant professionals such as dieticians if people needed to gain weight. However, the current system in place for recording people’s nutritional intake did not support the staff to clearly monitor what people had eaten daily, including any snacks to encourage weight gain.

Referrals were made to health professionals when there were concerns about a person’s wellbeing. However, people’s records did not always show the date of the visit or the guidance received. Care plans had not been updated to incorporate the guidance to ensure people received consistent care which met their needs.

The staff training matrix showed gaps in staff training in areas such as first aid, falls awareness, and the Mental Capacity Act. Following the inspection, the care operations manager confirmed further face to face training had been booked in various subjects to ensure staff were up to date in their knowledge and practice.

Improvements were required to ensure that good practice in dementia care was being followed, such as designing and decorating premises in a way that supports people. There were no dementia care plans so staff had no information to understand when people were diagnosed, which subtype of dementia they had, and how this would affect their lives as it progressed.

Medicines were managed safely, and staff were recruited with suitable checks in place.

The provider's oversight and monitoring systems and processes had not been effective and failed to appropriately manage risks to people and ensure adequate numbers of skilled staff were deployed. Auditing systems had not always led to immediate improvements when issues were found. There were limited systems to gain people’s feedback about their care, and feedback which had been received had not been used to drive improvements.

The registered manager was on leave at the time of the inspection, and there was a new manager in post. The provider was responsive to the inspection findings, they told us they were willing to learn, improve and share the actions they would take to address the issues found at this inspection.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating

The last rating for this service was good (published 25 December 2019).

Why we inspected

We received concerns in relation to the safety of people using the service and the high number of safeguarding referrals that had been made. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

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. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to inadequate based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective 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 and focused inspections, by selecting the ‘all reports’ link for Stradbroke Court on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, governance, staffing, consent procedures and safeguarding.

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.

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.