CQC report explained · a nursing home
What the CQC found at Banbury Heights Nursing 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, June 2023
Requires Improvement; inspectors found safer medicines management and enough staff, but risks and management oversight were still not dealt with properly.
This was an unannounced focused inspection on 2 May 2023. Inspectors looked at Safe and Well-led because concerns had been raised about safety and oversight. They spoke with 10 people, 5 relatives and 10 staff, and reviewed care records, medicines records, staff files and management records.
The home was still rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. Inspectors found gaps in records and risk management, including repositioning, unexplained bruising, distress, health conditions and conflicting care information.
Medicines were managed safely at this inspection, and staff recruitment checks were completed. People and relatives said they felt safe, and staff were described as kind and knowledgeable. However, governance systems had not reliably identified or corrected the problems.
The home had been rated Requires Improvement at the previous inspection in May 2022 and remains in breach of regulations. The provider introduced updated records and procedures during or after this inspection, but inspectors said these needed time to become established.
Medicines
Inspectors found that medicines management had improved and medicines were being managed safely during this visit.
“At this inspection medicines were managed safely.” from the report
Staff recruitment
The provider carried out references and criminal record checks before staff started work. Staff also received induction and training.
“The provider completed pre-employment checks such as references and Disclosure and Barring Service (DBS) checks.” from the report
People felt safe
People and relatives told inspectors they felt safe. Feedback described staff as kind and knowledgeable.
“People and relatives told us they felt safe at Banbury Height Nursing Home.” from the report
Open approach
The provider and registered manager were open during the inspection and introduced updated records and procedures.
“The provider and registered manager were open and transparent throughout the inspection.” from the report
Pressure damage risks
seriousRecords did not always show that people were repositioned as required. Two people's records had gaps of eight hours or more when repositioning was meant to happen every two hours.
“records for 2 people who required support to reposition themselves every 2 hours to reduce the risk of pressure damage evidenced gaps of 8 hours or more.” from the report
Unexplained bruising
seriousAn unexplained bruise had not been investigated. The home had not put measures in place to reduce the chance of it happening again.
“When a person had an unexplained bruise, the provider had not completed any investigations to identify the potential cause and to put mitigating factors in to reduce the risk of reoccurrence.” from the report
Incomplete care information
needs fixingSome care plans and risk assessments were missing information or contained conflicting information. Inspectors found an example involving food consistency and choking risk.
“Not all care plans and risk assessments held up to date, factual information.” from the report
Weak oversight
seriousManagement checks did not reliably identify missed care, incomplete records, missing mental capacity assessments or patterns in accidents and distress.
“Systems and processes were not effective in identifying when care had not been delivered in line with people's assessed needs.” from the report
- 01How will you make sure repositioning is completed and recorded at the intervals set out in each person's care plan?
- 02How are unexplained injuries or bruising investigated, and what action is taken to prevent them happening again?
- 03How do you check that care plans and risk assessments contain current and consistent information, including food consistency and health risks?
- 04What checks are now in place to identify missed care, incomplete mental capacity assessments and patterns in accidents or distress?
- 05What progress has been made in embedding the new systems introduced after the inspection, and how will you show that they are working?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their ratings carried over from the previous inspection. This explanation was written from the published report of 14 June 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, June 2022
Banbury Heights Nursing Home was rated Requires Improvement; inspectors found medicine safety and management systems needed urgent improvement.
This was an unannounced focused inspection on 27 and 28 April 2022. Inspectors looked at Safe, Effective and Well-led. They spoke with people, relatives, staff and healthcare professionals, observed care, and checked medicines, care records, staff records and quality checks.
The home was rated Requires Improvement overall. Safe and Well-led were rated Requires Improvement. Medicines were not always stored, administered or monitored safely. The home had also failed to report five safety incidents to the CQC and its checks had not found all the problems.
Effective was rated Good. People had their health needs assessed, could access healthcare, received suitable food and drink, and staff had relevant training. People said they felt safe and staff recruitment had provided enough staff. The provider took some action during the inspection, but improvements needed to be sustained.
The previous overall rating was Good, published in November 2019. The overall rating fell because of this focused inspection. Caring and Responsive were not inspected, so no new ratings were given for those areas.
Enough staff
Recruitment checks were completed and staffing numbers had been increased after reviewing people's needs and the building layout.
“Successful and safe staff recruitment had ensured there were enough staff available to meet people's needs.” from the report
Health support
People could see GPs and other healthcare professionals. Staff worked with specialist services when people's health needs changed.
“People could be seen by a GP when required.” from the report
Staff training
New staff received induction and support, and a training manager helped keep training relevant and up to date.
“Newly employed staff completed induction training and there were arrangements in place to monitor and support them until they were assessed as competent.” from the report
Food and drink
People were offered food and drink that matched their needs and preferences, including suitable textures for people with swallowing difficulties.
“People were provided with enough food and drink, to meet their individual dietary requirements and preferences.” from the report
Clean environment
Inspectors found effective infection prevention arrangements and people said their rooms were cleaned regularly.
“There were effective infection prevention and control arrangements in place and people lived in a clean environment.” from the report
Medicine safety
seriousMedicines were not always stored securely or given in line with guidance. There were also gaps in instructions for medicines given when needed and medicines given covertly.
“Medicines were not always managed safely to protect people from risks associated with medicines.” from the report
Safety incident reporting
seriousFive safety incidents involving people had not been reported to the CQC as required. This meant relevant agencies could not fully monitor the action taken to protect people.
“The provider failed to notify CQC of five safety incidents in accordance with legal requirements to ensure CQC could monitor the action they had taken to keep people safe.” from the report
Weak quality checks
seriousThe provider's audits did not identify all the problems found by inspectors. Monitoring of whether people received their agreed personal care was not developed enough.
“The provider did not have effective systems in place to monitor the quality and safety of the service.” from the report
Task-focused care
needs fixingAlthough the home had a person-centred vision, inspectors saw fewer meaningful interactions between staff and people than expected.
“However, we saw staffs' approach was often task focused with fewer meaningful interactions taking place with people.” from the report
- 01What changes have you made to medicine storage, covert medicines, pain patches and the reporting of medicine errors?
- 02How do you check that all safety incidents involving residents are reported to the CQC and other relevant agencies?
- 03How do you now check that each person receives the personal care recorded in their care plan?
- 04What evidence can you show that improvements identified through audits, complaints and incidents are being sustained?
- 05How are you increasing meaningful, person-centred conversations and activities for residents?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and no new ratings were given for them. This explanation was written from the published report of 14 June 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.
Every inspection of Banbury Heights Nursing Home
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- June 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Banbury Heights Nursing Home →
- June 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Banbury Heights Nursing Home →
- December 2020Inspected but not ratedSafe: Inspected but not rated
- November 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Requires improvement
- August 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 22 November 2010.
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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