CQC report explained · a nursing home
What the CQC found at Bakewell Cottage Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Medicines, staffing, infection control and emergency arrangements were found to be safe, although some equipment had not been stored safely.
- Effective?
- Good
- This key question was not inspected during this focused visit.
- Caring?
- Good
- This key question was not inspected during this focused visit.
- Responsive?
- Good
- This key question was not inspected during this focused visit.
- Well-led?
- Requires improvement
- The provider's oversight was not always strong enough to ensure that identified improvements were recorded, assigned and completed promptly. The registered manager had made sustained improvements, and people and relatives were positive about day-to-day management.
What inspectors found, March 2023
Bakewell Cottage Nursing Home was rated Good overall, but inspectors found weaknesses in provider oversight and unsafe equipment storage.
Inspectors visited unannounced on 14 February 2023. They spoke with people, relatives and staff, observed care, and checked care plans, medicines records, staffing records and quality checks.
The home was rated Good for safety. People were protected from abuse, medicines were managed safely, staff were safely recruited, and infection control arrangements were effective. Inspectors did find that some clean linen and mobility hoists were not safely stored. This was dealt with during and after the inspection.
The home was rated Requires Improvement for being well-led. The provider's checks did not always lead to a recorded improvement plan with clear actions, timescales and responsibilities. The overall rating improved from Requires Improvement at the previous inspection, but the well-led rating stayed the same.
This was a focused inspection of Safe and Well-led only. The other key questions were not inspected during this visit, so their previous ratings were used in the overall rating.
People felt safe
People and relatives said they felt safe and knew how to raise concerns. Staff understood how to recognise and report suspected abuse.
“People and relatives that we spoke with, all told us they felt safe, knew how and were confident to raise any safety concerns if they needed to.” from the report
Safe medicines
Inspectors found that medicines were ordered, stored, administered and disposed of safely. Staff had written guidance for applying prescribed skin creams.
“People's medicines were safely managed. This included the arrangements for their ordering, receipt, storage, administration and disposal.” from the report
Suitable staffing
Staff were safely recruited and were visible and responsive during the inspection. People, relatives and staff felt there were enough staff.
“Staff were safely recruited and deployed for people's care.” from the report
Kind, personalised care
Inspectors saw a welcoming atmosphere and good relationships. Staff knew people well and provided care in a personalised way.
“Staff were kind, caring and had good relationships with people and their relatives; knew people well and provided their care in a personalised way.” from the report
Improvement since the last inspection
The registered manager had made or was making improvements to care planning, medicines, the environment, cleanliness and infection control.
“Overall, the registered manager was able to demonstrate ongoing and sustained service improvement since our last inspection.” from the report
Provider oversight
needs fixingThe provider's quality checks did not always result in a written improvement plan. This meant actions, deadlines and responsibility for completing checks were not always clear.
“When management audits identified improvements needed, there was no recorded improvement plan to show related remedial actions agreed by the provider, timescales for achievement and who would be responsible for carrying out and monitoring their completion.” from the report
Equipment storage
seriousSome clean linen and mobility hoists, including hoists when charging, were not stored safely. The provider took immediate remedial action and this was later checked with the local fire authority.
“However, some equipment was not safely stored. This included the storage of clean linen and mobility hoists, including when charging.” from the report
- 01What permanent changes have been made to the storage of clean linen and mobility hoists?
- 02How do you now record improvement actions, deadlines and the person responsible for completing them?
- 03How do you check that actions identified by management audits have been completed and remain effective?
- 04What were the improvements to care planning and medicines systems mentioned in the report, and how are they monitored now?
- 05Which ratings from the previous inspection were carried forward because they were not assessed during this visit?
This was an unannounced focused inspection of Safe and Well-led; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 30 March 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, February 2020
Rated Requires Improvement; inspectors found kind, personalised care, but medicines guidance, recruitment records and quality checks still needed improvement.
This was an unannounced planned inspection on 7 January 2020. Inspectors spoke with 13 people, 10 relatives and 10 staff. They observed care, checked nine care records and several medicine records, reviewed two staff recruitment files, and examined management records.
The home had enough staff and people received kind, respectful and personalised care. Inspectors rated Effective, Caring and Responsive as Good. They found improvements in risk management, infection control, staff training, activities and working with health professionals.
Safe and Well-led were rated Requires Improvement. Some recruitment checks were not supported by retained documents. Guidance for some medicines and creams was not easy for staff to find. A repositioning record was incomplete, creating a risk that pressure relief might not be provided properly.
The overall rating means the home was not consistently meeting the standard expected. This was its third consecutive Requires Improvement rating. The report says all breaches from the previous inspection had been met, but further improvements still needed time to become established.
Kind and respectful care
People and relatives gave consistently positive feedback about staff kindness. Inspectors observed compassionate support and respect for privacy, dignity and personal choices.
“The registered manager ensured people were treated with kindness and compassion. This was reflected in the feedback we received.” from the report
Enough staff
Staffing levels were consistent and inspectors found enough qualified staff to meet people's needs and provide companionship.
“At this inspection we found staff were there were enough qualified staff on duty and they were deployed effectively to keep people safe.” from the report
Personalised activities
The home offered group and one-to-one activities, outings and visits from volunteers. Activities reflected people's interests and preferences.
“People were supported to take part in activities that were varied and designed with their personal preferences in mind.” from the report
Improved care planning
Care plans included people's likes, dislikes and important relationships. They were updated when people's needs changed.
“All care plans did contain information about peoples likes, dislikes, who was important to them and how they would like to be cared for.” from the report
Improved learning
The home had strengthened its approach to reviewing incidents and updating care plans and risk assessments to reduce the chance of problems happening again.
“At this inspection we saw improvements had been made. There was now a strong focus on continuous learning.” from the report
Recruitment records
needs fixingThe home did not always keep copies of identification checks for new staff. This meant it could not show that recruitment checks had been completed properly.
“The provider had failed to keep copies of appropriate identification checks they carried out with new employees.” from the report
Medicine guidance
needs fixingInstructions for medicines given when needed, and for applying some creams, were not always easy for staff to find. The home began creating clearer guidance during and after the inspection.
“Medicines that are prescribed as and when required (PRN) did not always have clear and available guidance for staff about what the medicine was prescribed for.” from the report
Repositioning records
seriousOne repositioning chart did not record the position staff had assisted the person into. Inspectors said this could increase the risk of sore skin, although daily checks were introduced after the inspection.
“This could lead to a person not being assisted to receive appropriate pressure relief and increase the risk of them developing sore skin.” from the report
Food choices
minorSome people and relatives said they were not offered enough choice, even though menus showed several options. The home planned new menus and pictorial menus after the inspection.
“Everyone we spoke with told us they enjoyed the food, however, some people and relatives told us they didn't feel they were offered enough choice.” from the report
- 01How do you now make sure guidance for as-needed medicines and skin creams is available to every member of staff?
- 02How are repositioning charts checked each day, and how do you act when a record is incomplete?
- 03How do you keep copies of identification checks and other recruitment documents for every new staff member?
- 04What changes have been made to menus and pictorial menus since the inspection?
- 05How are the remaining quality and governance improvements monitored and shown to be fully established?
This was an unannounced planned inspection covering all five CQC questions, following the home's previous Requires Improvement rating. This explanation was written from the published report of 22 February 2020 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 Bakewell Cottage Nursing Home
5 rated inspections over 7 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Bakewell Cottage Nursing Home →
- February 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Bakewell Cottage Nursing Home →
- July 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015
Registered with the Care Quality Commission on 14 May 2015.
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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