4 July 2023
During an inspection looking at part of the service
Vaughan Lee House is a residential care home providing personal care to up to 30 people. The service provides support to older people. At the time of our inspection there were 24 people using the service.
People’s experience of using this service and what we found
People's records did not always contain all the information staff needed to provide safe care. Some individual risks to people were not always thoroughly assessed and mitigated, and records relating to people's care were not always complete and reviewed.
The medicines system was not always robust. The recording of topical creams administration was not completed. Some people were prescribed medicines to be taken when required, there was a lack of guidance when this medicine should be administered.
People were not always supported to have maximum choice and control of their lives. The service could not always demonstrate they were working within the principles of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).
Recruitment procedures were not always robust, and staff did not always have appropriate training, support and detailed guidance to ensure people received safe care at all times.
The governance systems had failed to identify the areas for improvement that we found during the inspection. The shortfalls identified did not have any impact on the care and support people received. We discussed our concerns with the nominated individual and registered manager who were responsive to our feedback and started to take action to address the issues identified.
Staff understood how to protect people from poor care and abuse. Staff had training on how to recognise and report abuse and they knew how to apply it.
People told us they were happy; they felt safe, and the staff were kind and caring. Throughout the inspection we observed kind, relaxed, compassionate, and caring interactions between people and staff. Activities were provided for people, and they were supported to spend their time how they chose.
Rating at last inspection
The last rating for this service was good (published 18 May 2019).
Why we inspected
This inspection was prompted by a review of the information we held about this service.
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.
We have found evidence that the provider needs to make improvements. Please see the Safe, Effective and Well-led sections of this full report. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Enforcement and Recommendations
We have identified breaches in relation to safe care and treatment, safeguarding (DoLS), staff training and support and good governance at this inspection.
We have also made recommendations in relation to medicines, recruitment and need for consent.
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.