Archived: Emmaus House Residential Care Home

Updated 6 July 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 carried out by 1 inspector and 1 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

Emmaus House Residential Care 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. Emmaus House Residential Care Home 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 CQC 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.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 24 May and ended on 2 June 2023. We visited the service on 24 May 2023.

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

The inspection was carried out by conducting a site visit and speaking to some relatives and staff remotely. We spoke with 12 people who used the service and 4 relatives about their experiences of the care provided. We spoke with 11 staff including the nominated individual, registered manager, deputy manager, supervisors, care staff and a domestic. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records. This included 6 people’s care records. We looked at multiple medicines records. We reviewed 3 staff recruitment records. A range of records relating to the management of the service, including staff training records, accident and incident records, quality assurance checks, health and safety records and a sample of the provider’s policies and procedures were also reviewed. We received feedback from 2 health and social care professionals who work alongside the service.

Updated 6 July 2023

About the service

Emmaus House Residential Care Home is a residential care home providing personal care to up to 26 people. The service provides support to older people and people living with dementia or physical disabilities. At the time of our inspection there were 24 people using the service.

Emmaus House Residential Care Home accommodates people in one adapted building.

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

Although the provider had made some improvements since the last inspection, people were at risk of harm because the provider did not always understand their regulatory responsibilities. Systems were not always in place to assess, monitor and improve quality and safety across the service. The provider had not identified issues we found on inspection including with accidents and incidents and risks to people.

People were at risk of harm as risks to them were not always identified or recorded to guide staff in how to manage these. Where people used specialist mattresses to protect their skin from pressure damage, information on how these should be set was not recorded or known by care staff. Checks on equipment people used, such as bedrails were not always recorded to show their safety had been reviewed. We were not always assured accidents and incidents were reported to external organisations to share this information with them and seek appropriate advice.

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 did not always support this practice. We have made recommendations about Deprivation of Liberty Safeguards (DoLS) and CCTV used within the service.

Whilst shortfalls were identified in the leadership of the service, people’s experiences of their care were positive. People received person-centred care and decided their preferred routines. There was a strong culture of providing kind, compassionate care.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 03 November 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions safe and well-led which contain those requirements.

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 remained requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Emmaus House Residential Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment and good governance at this inspection. Please see the action we have told the provider to take at the end of this report.

We have made recommendations about DoLS and the use of CCTV in the service.

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.