Ponteland Manor Care Home

Updated 5 January 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 carried out by 2 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

Ponteland Manor 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. Ponteland manor 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.

What we did before the inspection

We reviewed the information we held about the service, including the statutory notifications we had received from the provider. Statutory notifications are reports about changes, events or incidents the provider is legally obliged to send to us. We contacted the local authority commissioning and safeguarding teams, the local NHS infection prevention and control [IPC] team and Healthwatch to request feedback. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

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 2 people who used the service and 15 relatives about their experience of the care provided. We spoke with 6 members of staff including the registered manager, deputy manager, nurse, domestic and agency staff. We reviewed a range of records. This included care records for 6 people. We looked at the recruitment records for 3 staff and a variety of records relating to the management of the service, including policies and procedures. After the inspection visits we requested additional information by email and continued to seek clarification from the provider to validate the evidence we found.

Updated 5 January 2023

About the service

Ponteland Manor Care Home provides nursing care and accommodation for up to 52 people. At the time of the inspection, 47 people were living at the home, some of whom had a dementia related condition. Accommodation is provided across two floors which has adapted to meet the needs of people.

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

Measures had been taken to respond to the findings from our last inspection to ensure improvements were made in relation to Infection Prevention and Control [IPC], the governance of the service and duty of candour.

Policies and procedures in relation to infection prevention and control (IPC) to prevent the spread of infections were in place. The registered manager reviewed government guidance in relation to COVID-19 and a member of staff was the identified infection control champion at the home. Arrangements were in place for people to receive indoor visits from relatives or friends. Medicines were managed safely and reviews of incidents took place to assess if any improvements to staff practice could be made. Systems were in place to share this learning with the staff team.

The service was well-led. Governance systems were effective in monitoring quality at the home. The registered manager worked in an open and transparent way and understood their responsibilities in relation to the duty of candour regulation.

Systems were in place to safeguard people from the risk of abuse and the risks people were exposed to had been assessed. There were enough staff deployed to meet people’s needs. Due to difficulties in recruiting permanent staff there was a reliance on the use of agency staff. This had impacted on the consistency of care. There had been a successful recruitment campaign and plans were in place for a number of new staff to commence employment. This would reduce the need for agency staff at the home. People and their relatives were complimentary about staff and of the care provided.

Staff had been recruited safely. However, records did not always demonstrate the necessary checks had been completed for agency staff prior to them working at the home. We have made a recommendation about this.

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.

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 13 June 2022) 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 improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We received concerns in relation to the management of an outbreak of COVID-19. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We also followed up on breaches identified at our last inspection.

We carried out an unannounced focused inspection of this service on 18 February 2022. 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, good governance and duty of candour.

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 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 of safe and well-led which contain those requirements.

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 changed from requires improvement to good based on the findings of this inspection.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well led sections of this full report.

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

Recommendations

We have made a recommendation under the safe key question the provider reviews their agency staff induction system to ensure records evidence the necessary checks have been undertaken.

Follow up

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