Catherine House Care Home

Updated 3 August 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

This inspection was undertaken by three 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

Catherine House Care Home is a 'care home' with nursing care. People in care homes receive accommodation, personal and nursing care as a single package under one contractual agreement dependent on their registration with us. 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 it was registered under the current provider. 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 18 people and 5 of their relatives. We also spoke with 16 staff including the registered manager, the lead nurse, nursing and senior care staff, care staff, activity lead, housekeeping, the cook, administrator and the maintenance person.

We reviewed a range of records. This included 14 people's care records and a sample of medication records. We looked at a variety of records relating to the management of the service, including training records, recruitment, incident records, complaints, compliments, quality assurance processes and various policies and procedures.

During the inspection we had 2 video calls with the nominated individual and 2 of the directors to discuss our findings and the actions they were taking.

After the inspection the registered manager and the provider’s senior management team sent us additional information about the service provided at Catherine House Care Home.

Updated 3 August 2023

About the service

Catherine House Care Home is located in the market town of Frome in North Somerset and is a detached building over 4 floors, with offices and storage on the ground floor and people receiving support on the first floor and second floor. At the time of the inspection, the third floor was undergoing a major refurbishment and was not being used. The service provides accommodation and nursing and personal care for up to 67 older, people, including people living with dementia. At the time of the inspection there were 51 older people living at the home.

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

People were not always protected from the risk of harm. The provider’s systems to audit the quality of the service were not robust or sufficient to alert the provider of concerns and issues within the service. The provider had failed to consistently identify risks to people's safety and wellbeing.

People’s personal records were not always stored securely. Staff had not understood their responsibilities for keeping personal information about people confidential.

After the first day of our visit one of the directors and the provider’s quality team visited the home to support the registered manager and identify any further shortfalls and risks. They took action and were transparent in sharing their findings.

People did not always have a good mealtime experience. We have made a recommendation that the provider continue to review and implements best practice guidance relating to person-centred support around mealtimes and choice of food.

On the first day of the inspection there were not always sufficient, trained staff deployed to meet people's needs across the home. The provider reviewed the staff levels and increased the staff numbers by the second day of our visit.

Some aspects of medicines management were not always being managed safely. Action was taken to improve medicine management during the inspection.

Staff did not always use PPE effectively and safely; we found some areas of the premises were not clean with unpleasant odours. Improvements were made to the infection prevention and control measures in place at Catherine House following our feedback on the first day.

People were protected from the risk of abuse. Staff had received safeguarding training and were confident to raise concerns.

People had their needs assessed before they moved to Catherine House and had care plans personalised for their needs. Improvements were made to people’s oral health care and personal care needs during the inspection. Staff identified people's information and communication needs by assessing them when they came to the home. Staff monitored people's on-going health conditions and made sure they had access to the local GP's and other healthcare services as needed.

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.

Improvements were made to ensure people’s social needs were being met. End of life discussions were taking place and were being documented.

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 5 November 2021, and this is the first inspection.

The last rating for the service under the previous provider was good, published on 15 October 2020.

Why we inspected

This inspection was carried out as it is a newly registered 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.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.