18 November 2022
During an inspection looking at part of 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.