30 November 2022
During an inspection looking at part of the service
Old Sarum Manor is a service providing accommodation and personal care for up to 66 people. The service provides support to older people over 65 years, people living with dementia, sensory impairment, physical disabilities and younger adults under 65 years. At the time of our inspection there were 66 people using the service.
Accommodation was provided over three floors accessed by stairs and a lift. People had their own rooms with en-suite facilities. There were also communal areas on each floor, including a cinema, café, hair salon, lounges and dining areas. People could access a secure garden from the ground floor.
People’s experience of using this service and what we found
Incidents and accidents had not consistently been reported to management so appropriate action could be taken in response. In addition, it was not always clear what actions were taken to prevent reoccurrence. This had been identified by the provider prior to our inspection and a new process was in place. This needed time to embed into practice. The provider also took responsive action during the inspection to review and improve systems.
Due to the shortfall in incident management there was an impact on duty of candour response letters. The provider took action to review this during the inspection and update responses sent to relevant people. The provider’s quality systems had not identified some of the incidents we found. We have made a recommendation about this.
Medicines had been managed safely. We did find some ‘as required’ protocols not in place. This had been identified by the provider prior to our inspection, action was being taken to put them in place. Staff had medicines training and checks on their competence regularly.
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.
The service was clean, and schedules were in place to make sure all areas of the home were checked. People and relatives told us they were very happy with the standards of cleanliness seen throughout the home. People had regular visits from friends and family, there were no visiting restrictions.
Staff wore personal protective equipment appropriately and had received training on good infection prevention and control procedures. Staff had been recruited safely and there were enough staff to meet people’s needs. People and relatives told us people felt safe at the service and they all appreciated the caring approach of the staff.
There was not a registered manager in post, however, an interim manager had applied to be registered prior to our inspection. People, relatives and staff told us the management of the service was inclusive, responsive and that management were approachable and visible. Systems were in place to give people and relatives opportunities to share their views and there were regular ‘residents meetings’.
Staff also had opportunities to meet regularly with management and they all told us they felt listened to and valued.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 2 November 2021).
Why we inspected
We received concerns in relation to medicines, senior staff interactions with people and people struggling to eat. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
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 did not find any evidence to substantiate the concerns received. We have however, found the provider needs to make improvements in other areas. Please see the key question safe section of this full report.
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 remained good based on the findings of this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Old Sarum Manor on our website at www.cqc.org.uk.
Recommendations
We have made one recommendation about the provider’s quality monitoring systems in the key question well-led.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.