White Rock Nursing Home Limited

Although incidents and accidents had been reported, investigated and lessons learned shared with staff, we noted that staff had not always reported incidents related to choking. We found some shortfalls in medicines management processes and oversight which included inconsistencies noted around temperature monitoring, the use of generic rather than personalised protocols and some aspects of medicine management record keeping lacked sufficient detail.

Safety checks had been carried out for the premises and for any equipment being used. However, we observed the use of stair gates to maintain people’s safety were not always secure or effectively managed. Although fire risks to people were assessed the provider had not ensured information was easily accessible in the event of an emergency such as a fire. However, risk assessments had been completed and regularly reviewed, and care plans informed staff how to keep people safe from harm.

Staff had the right skills, qualifications and experience to meet the needs of people and staff knew how to support people safely. Staff followed safeguarding processes and systems were effective to manage any safeguarding concerns that were reported. People had enough to eat and drink to stay healthy. Staff worked with all agencies involved in people’s care for the best outcomes and monitored people’s health to support healthy living.

Although the service needed refurbishment, plans were in place, and we saw that work had begun. The service was clean, and we observed staff following infection prevention and control guidelines.

Staff told us there was an open culture and they felt valued and respected by the management team. They spoke positively about the changes implemented by the new owner and told us they felt valued and listened to.

However, we were not assured the provider had effective governance systems in place. At this inspection we found the provider was in breach of the legal regulation for governance. Although quality assurance processes were in place to monitor all aspects of the service; systems and processes were ineffective and had not identified the shortfalls we found at this inspection. This included shortfalls in relation to risk management of choking, safe environments, medicines and consistent application of the mental capacity act for all relevant decisions. Although leaders were responsive to our feedback, systems and processes in place had failed to identify and drive improvements across the service delivery.