Lace Hill Manor Care Home

Updated 21 June 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 2 inspectors. An Expert by Experience made telephone calls to people’s relatives. 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

Lace Hill Manor 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. Lace Hill Manor Care Home 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 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 the Care Quality Commission 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 on the first 2 days; announced on the further 2 days to ensure access to the computer system and availability of the registered manager.

What we did before the inspection

We reviewed information we had received about the service since it was registered. We used the information the provider sent us in the Provider Information Return. 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 sought feedback from the local authority and other community professionals who work with the service. We emailed staff to seek their feedback on the service.

We used all this information to plan our inspection.

During the inspection

We spoke with the registered manager, regional director, a member of the quality team and a range of staff including care workers, the lifestyle coordinator and maintenance personnel.

We observed mealtimes, an activity and a daily managers’ meeting. We spoke with 4 people who used the service and received feedback from 21 relatives.

We checked a range of records. These included staff recruitment files, 8 people’s care plans, medicines records, a sample of audits, minutes of meetings, a sample of policies and procedures, training records and records relating to safety and upkeep of the premises.

After the inspection

We requested and received additional evidence from the provider to support our judgements. We continued to review this information until 23 May 2023.

Updated 21 June 2023

About the service

Lace Hill Manor Care Home is a care home providing personal and nursing care to up to 62 people. At the time of our inspection there were 23 people living at the home. The building is purpose built and each person had their own room with en-suite facilities. Accommodation was spread over 2 floors. People had access to a wide range of seating areas throughout the home. People also had access to facilities including a cinema room, hairdressing salon, private dining room for hire and a café/bistro area.

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

Care plans were in place for each person. These had not always been kept up to date and were difficult to follow, as multiple records were in place. Records of fluid intake and repositioning did not consistently show staff had carried out the interventions at the required intervals.

There were systems to audit the service and we could see actions were taken to make improvements. However, we found the issues we identified during the inspection had not been picked up in audits.

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. However, we found improvements were required in record keeping about decisions made in people’s best interests.

There were sufficient staff to meet people’s care needs. Pre-employment checks had been carried out to ensure staff had the necessary skills. People were protected from the risk of abuse. People we spoke with felt they or their relative were safe at the home. Any safeguarding concerns were reported to the local authority.

Risk assessments had been completed to reduce the likelihood of people being injured or harmed. People’s medicines were managed safely.

Staff followed good infection prevention and control practice. The home was clean and tidy throughout with good systems for managing laundry and adequate supplies of personal protective equipment.

Staff told us they felt supported and they completed numerous training courses. Training was updated during the course of the inspection.

People received a balanced diet and there was positive feedback about the quality of meals. We observed meals were unrushed and people were supported in a dignified manner.

People were cared for by staff who were caring, respectful and promoted their privacy, dignity and independence. Activities were available to provide stimulation and interest. We observed 1 activity where people enjoyed listening to a singer and some danced along to the music.

People were consulted about their care and asked for feedback in residents’ and relatives’ meetings.

People were supported to express their wishes regarding end of life care. The home had received numerous thank you cards from family or friends of people who had been cared for at the home.

People who provided feedback to us consistently said the registered manager was approachable and caring. Staff described the home as a good environment to work in and they felt listened to. The home offered its facilities to external organisations to use, to integrate the home with the local community.

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 12 April 2022 and this is the first inspection.

Why we inspected

This was a planned inspection for 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.

Enforcement and Recommendations

We have identified a breach in relation to governance of the service. We have made recommendations regarding recruitment records, improving fire drills, assessing the suitability of the environment for people with dementia and care planning.

Please see the action we have told the provider to take at the end of this report.

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.