Background to this inspection
Updated
19 May 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
This inspection was carried out by one inspector, a medicines inspector, an assistant inspector 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
Douglas House 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. Douglas House 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 they had registered with us. 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 ten people who used the service and one visitor. We spoke with 13 members of staff including the registered manager, deputy manager, operations manager, care workers, registered nurses, activities coordinator, kitchen staff and administrator.
We reviewed a range of records. This included seven people's care records and multiple medicine records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We also spoke with three relatives of people living at the service about their experience of the care provided.
Updated
19 May 2022
About the service
Douglas House is a residential care home providing regulated activity of personal and nursing care to up to a maximum of 30 people. People living in the home have a range of needs which include complex physical nursing needs and disabilities. At the time of the inspection 22 people were living at the service.
People’s experience of using this service and what we found
People were supported by staff who were kind and caring and who understood their needs, preferences and what was important to them. Staff respected people's privacy and dignity, encouraged people with making choices, and promoted independence.
People received person-centred care. Each person had personalised care plans which included information about people's life, their communication and their care needs and preferences. People were involved in care planning and reviewing their care.
Risk assessments detailed people's individual risks associated with people’s physical health needs and medical conditions as well as risks associated with nutrition, moving and handling, pressure ulcer prevention and choking.
People felt safe and were protected from the potential risk of harm and abuse. Staff understood their responsibilities for safeguarding people and followed the provider's policy and procedure.
Staff sought people's consent before providing support. 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.
The provider operated safe and robust recruitment and selection procedures to make sure staff were suitable and safe to work with people.
During the inspection we saw there were sufficient staff on duty to meet people’s needs. However, some people told us this was not always the case at weekends and at night. This was discussed with the provider who told us they had recognised this and this was being addressed.
People were supported to eat and drink a healthy and nutritious diet. There was a choice of meals and people's preference was sought.
People had access to a wide range of activities on offer, both within the service and in the community, to help prevent people becoming socially isolated and to keep people active.
There were systems in place to monitor the quality and safety of the service. Incidents and accidents were investigated, trends analysed, and actions were taken to prevent recurrence.
There were processes in place for people to raise any complaints and express their views and opinions about the service provided.
The premises were maintained and checked to help ensure the safety of people, staff and visitors.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 6 August 2019, and this is the first inspection.
Why we inspected
We undertook this inspection as the service had not had a rated inspection since registering with us.
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.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.