St Winifred's Dementia Residential Care Home

Updated 14 January 2021

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 Care Act 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 carried out by two inspectors and an assistant inspector supported the inspection off site.

Service and service type

St. Winifred’s 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.

The service had a manager registered with the Care Quality Commission. 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.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. 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 reviewed a range of records. This included three people’s care records and multiple medication records. We spoke with five people who live in the service, looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including quality assurance processes.

After the inspection

We continued to review documentation following the inspection, such as people’s care records and the company’s policies and procedures. We spoke to six relatives and gained feedback about the service.

Updated 14 January 2021

About the service

St Winifred's Dementia Residential Care Home is a residential care home providing personal and nursing care to 33 older people at the time of the inspection. The service can support up to 59 people in one large extended building.

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

People and their relatives told us they felt safe at the service. Allegations of abuse were reported to the local authority and investigated appropriately. Staff knew how to recognise signs of abuse and where to report them.

Improvements had been made to people’s care plans. People had risk assessments in place, and these gave staff the information they needed to safely look after people. Lessons had been learnt when things went wrong, and accidents and incidents were regularly analysed. People and their relatives felt there were enough staff to meet their needs. Staff were safely recruited, and pre- employment checks had been carried out.

People had their needs assessed before joining the service and care plans were put in place. Regular reviews of people’s needs were carried out and using recognised tools. Staff received training relevant to their job role. This was all up to date and staff felt confident within their roles. People were supported to have a healthy diet, given a choice of meals and where necessary adaptions were made based on individual needs.

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 had been made to the quality assurance processes. The registered manager and provider had oversight of systems within the service and made improvements where necessary. Staff told us they felt confident to raise concerns and that they felt they would be listened to. Relatives spoke highly of the management team, especially through the current pandemic. Staff received support through meetings and supervisions and were able to give feedback. The registered manager had introduced a system called ‘interactive me’ to help people stay in touch with their loved ones. The registered manager and provider gave out thank you cards and vouchers to staff who went above and beyond during the pandemic.

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 09 January 2020) and there were multiple 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 improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 01 and 03 December 2019, breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, person centred care and good governance.

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, effective and well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

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 coronavirus and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St. Winifred’s Dementia residential home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.