Archived: Eagles Mount Care Home

Updated 18 November 2020

The inspection

This was a targeted inspection to check the provider had taken action to correct shortfalls identified in the previous inspection. Shortfalls identified included environmental risk assessments, topical medicine management, some aspects of infection prevention and control and a repeated breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 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

The inspection was conducted by one inspector.

Service and service type

Eagles Mount Care 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. During this inspection the provider was in the process of removing their registration to provide nursing care.

Although the service did not have a current manager registered with the Care Quality Commission. The provider had employed a manager who was due to start their employment at the service on 26 October 2020. A registered manager and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection visit was unannounced.

What we did before the inspection

We reviewed information we had received about the service since our 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. 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 of this information to plan our inspection.

During the inspection

We spoke with two people who used the service, and spent time observing and listening to how staff interacted with people. The service had two deputy managers and we spoke with both of them, we also spoke with the facilities director and infection control lead, the maintenance technician, the operations director and the managing director.

We reviewed a variety of records relating to the management of the service. This included infection control audits, infection control policies, medicine management processes, risk assessments in relation to equipment and premises and policies and audits relating to the governance of the service.

After the inspection

We continued to seek clarification from the managing director to validate evidence found.

Updated 18 November 2020

About the service

Birds Hill Nursing Home is a nursing and care home for up to 72 older people some of whom may be living with dementia and or have nursing needs. The home is purpose built and is divided into three separate living units. There were 62 people living or staying there at the time of the inspection.

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

At the last inspection we identified a breach in regulations regarding the assessment and planning of people’s needs. Changes in their health were not always responded to appropriately to make sure all their healthcare needs were met in a timely way. These issues had been fully addressed at this inspection.

Also, at the last inspection, we also found a breach in regulations relating to systems to monitor and improve the quality and safety of the service. Some improvements have been made but this regulation remains in breach because some shortfalls regarding the oversight of the service were found at this inspection. In addition, we found some shortcomings in relation to infection control, risk assessment and medicines. We have made recommendations about these.

People told us that the service provided staff who were caring and supportive. They received care that was responsive to their individual needs and staff had a good understanding of how people preferred their care and support provided.

We saw people were very relaxed and content in the company of staff throughout our visits. Peoples needs were regularly assessed and reviewed in detail and action was taken to respond to people’s changing needs.

The provision of activities that were meaningful to the people living in the home was carefully planned. People told us they were happy with how they spent their time.

People had access to healthcare services and were involved in decisions about their care. Partnerships with other agencies and health professionals enabled effective outcomes for people. Staff supported people to take medicines safely.

The service supported people nearing the end of life to have a comfortable and dignified death by working closely with health care services and through consulting people about their end of life wishes. Staff talked with pride about the care they were able to give to people in their final days.

There were sufficient numbers of staff to meet people’s needs. Safe recruitment practices were followed, and appropriate checks completed to ensure that only suitable staff were employed. Staff received induction and on-going training and support that enabled them to carry out their roles positively and effectively.

Staff had completed safeguarding training and understood their role in identifying and reporting any concerns of potential abuse or poor practice.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People and where appropriate their relatives were involved in decisions about their care.

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 requires improvement (published 25 January 2019). The rating has now improved to good.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement We have identified one breach in relation to governance and oversight of the service 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 for the provider to understand what they will do to improve the standards of quality and safety. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.