CQC report explained · a residential care home
What the CQC found at Aldergrove Manor Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, August 2022
Aldergrove Manor Care Home was rated Requires Improvement; inspectors found concerns about medicines, staffing and management checks.
This was an unannounced focused inspection on 13 and 14 July 2022. Inspectors looked only at Safe and Well-led, because concerns had been raised about staffing, medicines, risk management and how the home was governed. They spoke with people, staff, a visiting health professional and relatives, and reviewed care, medicine, staffing and management records.
The home was not always safe. Some people did not consistently have their prescribed medicines available. Records for medicines, risks, fluid intake, catheter care and care plan reviews were not always complete or up to date. Inspectors also found that staffing checks had not been kept up to date, so they could not be assured there were always enough staff.
There were positive findings. Staff understood safeguarding and infection control, medicines were stored safely, and people and relatives generally spoke positively about the care and staff. However, the overall rating fell from Good at the previous inspection, published on 9 June 2021, to Requires Improvement because the inspection found that improvements were needed.
Safeguarding
Staff understood how to recognise and report abuse. The manager had a system for reporting incidents to the appropriate bodies.
“Staff understood the signs of abuse and how to report any concerns.” from the report
Infection control
Inspectors were assured that infection prevention measures, including PPE, testing, hygiene and visiting arrangements, were in place.
“We were assured that the provider was using PPE effectively and safely.” from the report
Respectful staff
People, relatives and staff described the manager as supportive and approachable. People and relatives also spoke positively about staff and the care received.
“People relatives and staff all expressed how supportive and approachable the registered manager was.” from the report
Working with other services
The manager had relationships with local health and social care providers and sought advice to improve care.
“The registered manager had established relationships with local health and social care providers.” from the report
Medicines not always available
seriousOne person went without a prescribed medicine for several days. Inspectors said this placed the person at risk of harm, although no adverse effects were found.
“One person had been without their prescribed medicine for several days.” from the report
Staffing levels
needs fixingRelatives and most staff said there were not always enough staff. The staffing assessment tool had not been updated for everyone, including some new admissions.
“The providers systems for ensuring staffing levels at the home were adequate had not been followed to ensure there was enough staff.” from the report
Incomplete monitoring records
needs fixingFluid and catheter monitoring charts contained missed entries. Inspectors said this meant improvements were needed in how risks were assessed, monitored and managed.
“we found fluid monitoring charts and catheter monitoring charts with missed entries.” from the report
Weak management checks
seriousAudits did not reliably identify missing or outdated records, medicine stock problems, staffing assessment gaps or care plan issues. This was linked to the breach of Regulation 17.
“Systems were not effective in identifying where records had not been updated and completed effectively and medicines were administered as prescribed.” from the report
- 01What action have you taken to make sure every person has their prescribed medicines available when needed?
- 02How do you now check that staffing levels match each person's needs, including new admissions?
- 03How are fluid intake, catheter care and other monitoring charts checked for missed entries?
- 04How often are care plans and risk assessments reviewed and updated after people's needs change?
- 05What progress has been made on the action plan requested by CQC after the Regulation 17 breach?
This was an unannounced focused inspection of Safe and Well-led only; the other question ratings carried over from the previous inspection. This explanation was written from the published report of 18 August 2022 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, June 2021
Rated Good; inspectors found safe, well-managed care, but this was a focused inspection of only two areas.
Inspectors made an unannounced visit on 12 May 2021. They spoke with people, relatives, staff and a health professional. They checked care records, medicines records, recruitment files, audits and other management records.
The inspection was prompted by a serious incident involving a death and concerns about knowledge of Do Not Attempt Cardiopulmonary Resuscitation decisions. The report says the inspection did not examine the circumstances of that incident because it was subject to a criminal investigation. Inspectors found no evidence that people were at risk of harm from the concern they examined.
Safe and well-led were both rated Good. Inspectors found safe medicines systems, enough staff, appropriate risk assessments, suitable infection control measures and management checks. The acting manager was described as accessible, and people, relatives and staff spoke positively about the home.
This was a focused inspection, not a full review of all five areas. The ratings for Effective, Caring and Responsive came from the previous comprehensive inspection.
Safety and risk management
People's risks were assessed and updated when their needs changed. Staff knew people's risks and supported them to avoid harm.
“Where people's risks had changed, we found care plans and risk assessments had been reviewed and updated” from the report
Medicines
People received medicines as prescribed. Records checked for controlled medicines were accurate.
“We found records we checked relating to the administration, storage and disposal of these medicines were accurate.” from the report
Responsive staffing
Inspectors saw enough staff to support people in shared areas and their rooms. Staff responded promptly when people used call bells.
“Where people used the call-bell system to request support, staff responded without delay.” from the report
Management and learning
The management team used audits and incident reviews to identify improvements. Staff received extra training when needed.
“Where incidents or events had occurred, we saw evidence that learning had been undertaken by the management and staff team.” from the report
Family involvement
Relatives said they were happy with visiting arrangements during the pandemic. The home also used other ways to keep families involved.
“Relatives told us they were happy with the arrangements for visiting their loved ones during the pandemic.” from the report
Time to talk with people
minorOne person and a small number of staff said they would like staff to have more time to talk with people. This feedback was passed to the acting manager.
“One person felt they would benefit from some more time to talk with staff.” from the report
Further infection control development
minorInspectors were assured about the home's infection control arrangements, but signposted the provider to resources to develop its approach.
“We have also signposted the provider to resources to develop their approach.” from the report
Staff feedback not yet reviewed
minorStaff feedback was being collected but had not yet been reviewed by the provider when inspectors visited.
“Staff feedback was being gathered at the time of the inspection and was yet to be reviewed by the provider.” from the report
- 01How are Do Not Attempt Cardiopulmonary Resuscitation decisions explained, recorded and checked with residents and families?
- 02What action has been taken to give staff more time to talk with people?
- 03What did the review of staff feedback find, and what changes followed?
- 04What infection control improvements were made after CQC signposted resources to the provider?
- 05How is the acting manager supported while the registered manager is on leave?
This was an unannounced focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive came from the previous comprehensive inspection. This explanation was written from the published report of 10 June 2021 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 Aldergrove Manor Care Home
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- August 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2021GoodSafe: GoodWell-led: Good
- March 2021Inspected but not ratedSafe: Inspected but not rated
- January 2018GoodSafe: GoodWell-led: Good
- February 2016
Registered with the Care Quality Commission on 19 February 2016.
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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