CQC report explained · a residential care home
What the CQC found at Bentinck Crescent
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2023
Bentinck Crescent is rated Requires Improvement; inspectors found kind and safe support in some areas, but serious gaps in medicines, risk management, consent and personalised activities.
This was an unannounced focused inspection on 11 and 18 September 2023. Inspectors observed care, spoke with one person, four relatives and four staff, and reviewed care, medicines and management records.
The home was rated Requires Improvement overall. Safe, Responsive and Well-led were all rated Requires Improvement. The inspection found breaches involving medicines, risk management, consent, person-centred care and quality monitoring.
People and relatives generally said staff were kind and people felt safe. However, some people did not receive their medicines safely, fire evacuation arrangements were not up to date, and activities and outings did not always match people's wishes.
This was a change from the previous Good rating, published on 22 September 2022. The inspection was focused on Safe, Responsive and Well-led, so the other ratings carried over from the earlier inspection.
People felt safe
People and relatives generally felt that people were safe and staff were kind. Staff knew how to recognise and report abuse.
“People and their relatives were happy with the care people received. People felt safe and that staff were kind.” from the report
Enough staff during the visit
Inspectors saw enough staff to support people safely during the visit. Recruitment was under way, although agency staff were also being used.
“We observed there were enough staff to support people safely during the site visit.” from the report
Communication support
Staff knew how people communicated and responded quickly to their communication needs.
“People's communication needs were met. Staff knew people's methods of communication well and reacted to their needs swiftly.” from the report
Infection control
Inspectors were assured that infection prevention measures, including use of protective equipment and outbreak arrangements, were in place.
“We were assured that the provider was using PPE effectively and safely.” from the report
Medicines were not always safe
seriousMedicine records were incomplete, including for medicines given when needed. The home could not assure inspectors that there was enough time between doses.
“Medicines were not always managed safely. Medicine administration records were not maintained in line with best practice guidance.” from the report
Fire risks were not dealt with promptly
seriousFire safety measures were out of date. There had been only one evacuation practice in the previous year, involving two staff, and it did not follow the home's plan.
“There was only one fire evacuation practice in the last year, which two members of staff took part in.” from the report
People lacked activities and outings
needs fixingSome recorded aspirations, such as swimming, were not being supported. There were not always enough staff or drivers for people to go out when they wanted.
“There was a lack of meaningful activities for some people.” from the report
Consent records were incomplete
seriousMental capacity assessments and best-interest decisions were missing for some decisions. Most Deprivation of Liberty Safeguards authorisations were significantly out of date.
“Mental capacity assessments and best interest decisions were not in place for all decisions.” from the report
- 01What has been changed to make sure medicines, including as-required medicines, are recorded and given safely?
- 02When was the last full fire evacuation practice, and how are you making sure all staff can follow the evacuation plan?
- 03How will you support each person to achieve their recorded aspirations, including swimming, trips out and other meaningful activities?
- 04Have all mental capacity assessments, best-interest decisions and Deprivation of Liberty Safeguards applications been completed and updated?
- 05How will you show that quality checks are finding problems and that improvements are being kept in place?
This was an unannounced focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and the previous ratings were carried forward. This explanation was written from the published report of 23 November 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, September 2022
Bentinck Crescent is rated Good; inspectors found safe, caring support but gaps in medicines records and checks.
This was an unannounced focused inspection. Inspectors visited on 17 August 2022 and completed inspection activity on 22 August 2022. They reviewed care and medicine records, audits and other information, and spoke with people, relatives, managers and support workers.
The home was rated Good for Safe and Well-led. Inspectors found enough skilled staff, a clean and suitable environment, appropriate safeguarding and infection control, and staff who understood people's communication and support needs.
There were gaps in medicines records. Some staff initials were missing from Medicine Administration Records, handwritten entries were not always countersigned, and the medicines audit system had not identified or corrected this. Inspectors made recommendations about medicines recording, storage and audits.
This was a focused inspection of Safe and Well-led only. The other areas were not inspected and their ratings were carried forward from the previous inspection. The overall rating remained Good, as it was at the last inspection.
Enough trained staff
There were enough skilled staff to meet people's needs and keep them safe. Staff had relevant training, including training for specific medicines.
“There were enough skilled staff to meet the needs of people using the service.” from the report
Personalised support
Staff understood people's individual communication needs and supported them in a compassionate and empowering way.
“This meant people received compassionate and empowering care that was tailored to their needs.” from the report
Safe environment
People lived in a clean, well-equipped and well-maintained home that met their sensory and physical needs.
“People were supported in a safe, clean, well equipped, well-furnished and well-maintained environment that met their sensory and physical needs.” from the report
Supportive management
Staff described the management as approachable and supportive. They said concerns and suggestions were listened to and acted on.
“Staff said the registered manager was very approachable and supportive.” from the report
Incomplete medicines records
needs fixingSome Medicine Administration Records were missing staff initials, so it was not always clear whether medicines had been given. Handwritten entries were not always countersigned.
“Medicine Administration Records (MAR) charts were not always completed in full.” from the report
Medicines fridge temperatures
needs fixingOn two occasions the medicines fridge was below the recommended minimum temperature. The provider replaced medicines, contacted the GP and began an investigation.
“However, on two occasions the minimum temperature of the refrigerator was below the recommended temperature of two degrees Celsius.” from the report
Medicines audits missed problems
needs fixingThe home's medicines checks had not reliably identified incomplete records or ensured that action was taken promptly.
“However, these had not been effective in ensuring MAR charts were fully completed and action taken as and when needed.” from the report
Some relatives wanted more communication
minorMost relatives said communication was positive, but one relative wanted greater involvement and more frequent communication.
“One relative commented that they would like to be more involved and would like more frequent communication.” from the report
- 01How are Medicine Administration Records checked now to make sure every dose has a staff initial and handwritten entry is countersigned?
- 02What changes were made after the medicines refrigerator was below the recommended temperature?
- 03How often are medicines audits completed, and who checks that any problems are corrected promptly?
- 04How will you keep relatives informed and involve them in their family member's care?
- 05What were the ratings for Effective, Caring and Responsive at the previous inspection?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 22 September 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 Bentinck Crescent
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- November 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2022Goodstayed GoodSafe: GoodWell-led: Good
- April 2020Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Good
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 20 December 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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