CQC report explained · a nursing home
What the CQC found at Bennetts Castle Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that people were protected from avoidable harm. Risk assessments, medicines management, staffing, recruitment, infection control and safeguarding systems were in place, although the annual water safety check was overdue.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- Inspectors found effective audits and monitoring, an open culture, clear staff roles and involvement of people, relatives and staff in improving the service.
What inspectors found, April 2023
Bennetts Castle Care Centre was rated Good; inspectors found safer systems and better management, with one overdue water safety check.
This was an unannounced focused inspection on 13 March 2023. Inspectors spoke with people, relatives, staff and health professionals. They observed care and checked care records, medicines records and management documents.
The inspection looked only at Safe and Well-led. Both were rated Good. Inspectors found enough staff, safer medicines systems, suitable risk assessments, infection control measures and systems to learn from accidents and incidents.
The home had improved since the previous inspection, which was rated Requires improvement and had breaches of regulations. The provider had completed an action plan, and inspectors found the earlier problems had been addressed. The overall rating changed to Good, with the other question ratings carried forward from the previous inspection.
Clear risk assessments
Risk assessments covered health conditions, medicines, mobility, falls, skin care and nutrition. They were reviewed monthly.
“Risk assessments were in place for people. These were of a good standard, comprehensibly setting out the risks people faced and they included information about how to mitigate those risks.” from the report
Safer medicines
Medicines were stored securely and administration records had no unexplained gaps. Guidance was available for medicines given when needed.
“Medicines administration records were maintained so there was an audit trail for all medicines administered. We found these were completed correctly without any unexplained gaps.” from the report
Enough staff
Inspectors saw staff respond promptly to requests and alarm calls. Recruitment checks were also in place.
“There were enough staff to meet people's needs. Staffing levels were set by the use of a dependency tool, which worked out the level of support each individual required.” from the report
Improved quality checks
The provider had introduced audits covering areas such as infection control, medicines and health and safety. Care plans and risk assessments were reviewed regularly.
“Effective quality assurance systems had been implemented by the provider. These included various audits.” from the report
Open culture
People, relatives and staff described the home as open, positive and well run. People had opportunities to share their views through meetings and surveys.
“There was a positive culture at the service which was open and inclusive.” from the report
Water safety check overdue
minorThe annual water safety check had not been completed by the inspection. The provider said it had been booked for the end of March 2023.
“However, the annual check for water safety was overdue.” from the report
- 01Has the overdue annual water safety check now been completed, and were any problems found?
- 02How are risk assessments reviewed each month, especially for diabetes and seizures?
- 03How do managers check that medicines records, PRN guidance and medicated cream instructions remain complete?
- 04What were the ratings for Effective, Caring and Responsive at the previous inspection?
- 05How can residents and relatives raise concerns or suggest changes between meetings and surveys?
This was an unannounced focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection. This explanation was written from the published report of 18 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, June 2022
Rated Requires Improvement; inspectors found staffing and infection control were satisfactory, but risks, medicines and quality checks were not always managed safely.
The inspection was unannounced and took place on 27 April 2022. Inspectors spoke with people, relatives and staff. They observed care and checked care records, medicines, recruitment files and records about running the home.
The home had enough staff, safe recruitment checks and systems to protect people from abuse. Infection prevention measures were in place. People and relatives generally said they felt safe, and staff were described as helpful and kind.
However, some people did not have proper risk assessments for diabetes or seizures. Inspectors also found medicines stock records that did not match, missing guidance for some as-required medicines and no body maps for some prescribed creams.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. The previous overall rating was Good in 2018. The provider was required to send an action plan, and CQC said it would monitor progress.
Enough staff
Inspectors found enough staff to keep people safe and saw staff respond promptly when people needed help.
“There were enough staff working at the service to keep people safe.” from the report
Infection control
Inspectors were assured that the home had measures in place for preventing and managing infections, including the safe use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Safeguarding systems
The home had systems for reporting and recording abuse allegations. Staff had safeguarding training and understood their duty to report concerns.
“Comprehensive records were maintained of any allegations of abuse and subsequent action taken.” from the report
Open culture
People, relatives and staff described the culture as open and positive. Staff said the manager was approachable.
“The provider had a positive culture that was open and person centred.” from the report
Missing health risk assessments
seriousRisk assessments were missing for some people with diabetes and for one person at risk of seizures. This left staff without clear written guidance.
“This meant there was a lack of clear guidance to staff about how to support people with the risks associated with these health conditions.” from the report
Medicine records and guidance
seriousThree medicine stock balances did not match the recorded amounts. One person had three as-required medicines without written protocols, and some creams did not have body maps.
“We found three instances where the stock balances did not reflect the amounts recorded as being in stock” from the report
Quality checks missed problems
needs fixingThe home's audits had not identified the missing risk assessments or medicine issues found by inspectors.
“However, quality assurance systems were not always effective.” from the report
No registered manager
needs fixingThere was no registered manager in post at the inspection. A manager was in post and was applying for registration.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01Have written risk assessments now been completed for every resident with diabetes or a risk of seizures?
- 02How do you check that medicine stock balances match the medicines actually held?
- 03Are written protocols now in place for every as-required medicine?
- 04Are body maps now used to show staff where prescribed creams must be applied?
- 05What changes have you made to quality audits so they identify these problems before they put people at risk?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 17 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 Bennetts Castle Care Centre
5 rated inspections over 8 years: the service has held its Good rating throughout.
- April 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- September 2018Goodstayed GoodSafe: GoodWell-led: Good
- April 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- January 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 30 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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