CQC report explained · a residential care home
What the CQC found at Lathbury Manor Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments had improved, but people were sometimes left without sufficient supervision, one person did not receive medicines as prescribed, some injuries were not fully recorded, and some areas needed extra cleaning.
- Effective?
- Requires improvement
- This question was not inspected during this visit. Its previous rating was carried forward.
- Caring?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- The management team was committed to improvement and staff felt supported, but systems for checking risks, medicines and records were still not effective enough. This was a continued breach of Regulation 17.
What inspectors found, April 2023
Requires Improvement; inspectors found better risk assessments but concerns about staffing, medicines, cleanliness and management checks.
This was an unannounced, focused inspection on 20 March 2023. Inspectors looked only at Safe and Well-led. They spoke with people, relatives and staff, observed care, and checked care, medicine, staff and management records.
The home had improved some risk assessments and safeguarding procedures. However, inspectors found people at risk of falls were sometimes left without enough supervision. One person did not receive medicines as prescribed, some injuries were not fully recorded, and some areas and equipment needed more cleaning.
Management checks had improved but were not yet reliable. They had not found all the problems before the inspection. The home remained in breach of Regulation 17, so the overall rating stayed Requires Improvement. The other three question ratings were carried forward from the previous inspection.
Improved risk assessments
Inspectors found that risk assessments had been updated and included enough information about known risks. The risk from one person's behaviour had also been reduced through additional staffing.
“At this inspection we found risk assessments had been updated and contained sufficient information.” from the report
Staff knew people well
People and relatives were involved in care planning. Relatives said staff understood the people they supported and kept them informed about important changes.
“People and their relatives were involved in the care planning and reviews of care plan documents.” from the report
Safer recruitment
The provider completed checks before staff started work, including references and criminal record checks.
“Safer recruitment checks had been completed before staff started working at the service.” from the report
Supportive management culture
Staff said they felt supported, valued and listened to. The management team was open to feedback and committed to improving the service.
“The management team were committed to improving the service.” from the report
People not always supervised safely
seriousInspectors saw people, including people at risk of falls, left unsupervised in communal areas. Some relatives also reported delays in getting help at night.
“This included people who were at risk of falls and required staff supervision when mobilising.” from the report
Medicine not given as prescribed
seriousOne person received a medicine three times a day when the prescription said four times a day. The manager contacted the GP after the inspection.
“One person had not been receiving their medicines as prescribed.” from the report
Management checks missed problems
seriousAudits had improved but had not identified concerns about medicines, cream expiry dates, injuries and other care records before the inspection. This resulted in a continued breach of Regulation 17.
“However, these still needed to be embedded and sustained into practice.” from the report
Injuries and causes not always recorded
needs fixingNot all injuries or possible causes were recorded. Incident reviews also needed more detail about where incidents happened and who was present.
“We found not all injuries or potential cause for the injuries had been recorded.” from the report
Cleaning needed improvement
needs fixingInspectors found areas and equipment that needed more cleaning. The manager arranged extra cleaning immediately after the inspection.
“We found areas and equipment within the home that required additional cleaning.” from the report
- 01How are staff deployed across the different communal areas to supervise people at risk of falls?
- 02What checks now make sure every medicine is given at the prescribed dose and frequency?
- 03How do you record injuries, possible causes and whether falls were witnessed?
- 04What changes have been made to the management audits since this inspection, and how will you show they are working?
- 05What extra cleaning has been introduced, and how is its standard checked?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were carried forward from the previous inspection. This explanation was written from the published report of 14 April 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2023
Requires Improvement; inspectors found risks linked to distressed behaviour and weak oversight, although staffing, medicines and healthcare support were positive.
This was an unannounced inspection on 13 and 26 September 2022. Two inspectors and an Expert by Experience spoke with people, relatives and staff, and reviewed care, medicines, recruitment and management records.
The home was not always safe. Some risk assessments did not explain people's triggers or how staff should respond when distressed behaviour could cause harm. Incident reviews were also not detailed enough to show that lessons had been learned. The home remained in breach of regulations 12 and 17.
There were also concerns about mealtimes and staff training for physical intervention. Inspectors found that medicines systems, staffing levels, recruitment, infection control, healthcare referrals and Mental Capacity Act processes were working more reliably.
The overall rating is Requires Improvement. Safe, Effective and Well-led were all rated Requires Improvement. The home has had this rating for the last two consecutive inspections, and the other key question ratings were carried forward because they were not inspected this time.
Medicines systems
Medicines were ordered, stored and administered through established systems. Staff administering medicines had been trained.
“Systems were followed for ordering, receiving and storing medicines.” from the report
Staffing and recruitment
Inspectors found enough staff to meet people's needs and safe recruitment checks were completed.
“There were sufficient staff available to meet people's needs.” from the report
Healthcare support
The home made referrals to relevant health professionals and followed their advice when people's health or nutrition needed further support.
“Referrals were made to the appropriate health professionals as required” from the report
Choice and legal safeguards
People were encouraged to make decisions about their care and daily routines. Best-interest decisions and required applications were recorded.
“People were encouraged to make decisions about their care and their day-to-day routines and preferences.” from the report
Incomplete behaviour risk plans
seriousSome risk assessments did not describe likely triggers or how staff should intervene safely when people became distressed. This was a continued breach and created a risk of harm.
“The provider had not made sure risk assessments had detailed information for managing risks associated with behaviours that had the potential to cause harm to self and others.” from the report
Weak incident oversight
seriousAudits and management meetings had restarted, but records did not show detailed analysis or enough action to prevent incidents happening again. This was a continued breach.
“Systems and processes were not operated effectively to enable the provider to identify where quality and/or safety were being compromised and to respond appropriately and without delay.” from the report
Mealtime supervision
needs fixingA person took food from another person's plate without staff noticing. Inspectors said this risked the person not eating their meal and having a poor mealtime experience.
“This had placed the person at risk of not eating their meal, and of having a very poor mealtime experience.” from the report
Physical intervention training
needs fixingStaff had needed to physically intervene during incidents, but this was not included in their training programme. Inspectors recommended that the provider seek guidance based on current legislation.
“The use of physical intervention was not included in the staff training programme.” from the report
Communication and feedback
needs fixingRelatives' and residents' meetings had not been re-established, and the home did not sufficiently show how it sought and acted on feedback from everyone using the service.
“However, this approach did not sufficiently evidence how the provider seeks and acts on feedback from all people using the service, relatives' and stakeholders, to continually evaluate the service and drive improvement.” from the report
- 01What changes have been made to risk assessments for people who may become distressed or behave in ways that could harm themselves or others?
- 02How do you analyse incidents now, and how do you check that action has prevented similar incidents happening again?
- 03What training do staff now receive in physical intervention, and how do you check they are competent to use it safely?
- 04How are mealtimes supervised so that people receive and can enjoy their own food?
- 05What regular meetings or questionnaires are now used to gather feedback from residents and relatives?
This was a focused inspection of Safe and Well-led, widened to include Effective; Caring and Responsive were not inspected and their previous ratings were used for the overall rating. This explanation was written from the published report of 6 January 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Lathbury Manor Care Home
8 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- April 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2023Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- February 2021Goodstayed GoodSafe: GoodWell-led: Good
- May 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- April 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Goodstayed GoodCaring: Good
- May 2015GoodSafe: GoodEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- July 2012
Registered with the Care Quality Commission on 13 July 2012.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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