CQC report explained · a nursing home
What the CQC found at Bentley Court 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, October 2022
Bentley Court Care Home is rated Good overall, with kind and safe care, but leadership and record-keeping still require improvement.
Inspectors visited on 5 and 22 August 2022 without announcing the visits. They spoke with people, relatives and staff, observed care and reviewed care, medicines, recruitment and management records.
The overall rating was Good. Safe, effective, caring and responsive care were all rated Good. People were generally safe, treated kindly, supported to make choices and helped with their health, food, communication and activities.
Well-led was rated Requires Improvement. The home had made many improvements since its previous Inadequate rating, including a new electronic care planning system and more quality checks. However, some care and medicines records were still incomplete or inconsistent.
Safety improvements
The home had acted on earlier concerns about fire safety, building maintenance, infection control and delays in responding to health concerns.
“Lessons had been learned since the last inspection. Concerns had been promptly acted upon and measures put in place to improve the safety of people's care.” from the report
Kind and respectful care
People said staff were caring and listened to them. Inspectors saw staff respect choices about personal care, clothing protectors and where people spent their time.
“People told us staff listened to them. One person said, "Staff listen to what I want.” from the report
Personalised support
Care plans had been reviewed and included detailed information about people's needs and preferences. Staff knew people and supported their communication needs.
“Care plans contained detailed information about people's needs and preferences.” from the report
Positive leadership changes
A new electronic care planning system, regular clinical meetings and quality checks had been introduced. People, relatives and staff reported that things had improved.
“Many improvements had been made since the last inspection; a new electronic care planning system was put in place and quality assurance systems introduced.” from the report
Incomplete care records
needs fixingSome assessments were not fully completed or did not agree with each other. Inspectors said this did not put people at risk during the inspection, but records needed to be completed correctly.
“A person's nutritional risk was identified in one plan as 'very high risk', but in another assessment it stated there was no risk.” from the report
Medicines recording
needs fixingThere were missing instructions, a missing date and two stock discrepancies. The home had introduced more frequent audits, but its systems had not identified all the problems at the time of the visit.
“There were some omissions in medicines recording. For example, one person had missing instructions for their topical creams, there was one missing date recording for a person's medicine patch and there were two stock discrepancies.” from the report
Shared activity equipment
needs fixingEquipment used during exercise activities was not decontaminated between different people. Inspectors said the home should consider how to manage this safely.
“We observed activity staff doing exercise activities with people using equipment and these were not decontaminated between being used by different people;” from the report
Staffing pressure
minorPeople generally received prompt help, but staff gave mixed feedback about staffing levels. Inspectors observed extra pressure when staff took afternoon breaks.
“There was some mixed feedback about staffing levels, however there were enough staff to support people.” from the report
- 01How do you now check that care assessments are complete and that information about risks agrees across all records?
- 02What checks are made on medicines records, topical cream instructions, medicine patch dates and stock levels?
- 03How is shared equipment cleaned between people during exercise activities?
- 04How do you make sure there are enough staff during afternoon breaks and at busier times?
- 05What further plans are in place to expand activities and meet individual interests?
This was an unannounced follow-up inspection covering all five quality questions, after the previous Inadequate rating and action plan. This explanation was written from the published report of 4 October 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, April 2022
Rated Inadequate and placed in special measures; inspectors found serious safety and management failures despite kind care from staff.
Inspectors visited on 8 and 16 February 2022 without announcing the inspection in advance. They spoke with people living at the home, relatives and staff, observed care, and checked care, medicines, recruitment and management records.
They found serious problems with infection control, fire safety, medicine storage, recruitment checks and responses to changing health needs. People could not be assured that the home was safe or well managed. The inspection found breaches of regulations about safe care, consent and good governance.
There were also shortfalls in person-centred care, involving people in decisions, timely healthcare referrals and activities. Staff were trained, and inspectors saw kind and respectful care in many interactions. However, the overall rating was Inadequate, and the home was placed in special measures.
Trained staff
Staff completed training and induction, and told inspectors they felt supported by the management team.
“It gave me the knowledge and confidence to do my job.” from the report
Kind interactions
Inspectors saw many respectful and compassionate interactions. People were encouraged to remain as independent as possible.
“We observed many respectful and compassionate interactions during the inspection.” from the report
Learning from incidents
Accidents and incidents were recorded and investigated, with action intended to prevent them happening again.
“Accidents and incident were fully documented and investigated to identify ways of preventing them from happening again.” from the report
Complaints process
The home had a complaints procedure, and records showed complaints, responses and lessons learned.
“The provider had a complaints procedure that was followed and records of complaints and the response and any lessons learned were documented.” from the report
Unsafe environment
seriousA fire exit and two fire extinguishers were blocked. An unlocked cupboard contained alcohol gel, and remedial work identified in a fire risk assessment had not been completed.
“During the inspection we saw a fire exit and two fire extinguishers that were blocked by equipment.” from the report
Infection control
seriousStaff did not consistently follow infection control procedures. Inspectors saw problems with cleaning, PPE, isolation and movement between areas during a COVID-19 outbreak.
“We were not assured that the provider was using PPE effectively and safely.” from the report
Medicine storage
seriousPrescribed drink thickeners were kept in an unlocked drawer and cream needing refrigeration was stored in an unrefrigerated cabinet.
“We found two tins of a prescribed drink thickener that was store in an unlocked drawer in a dining room.” from the report
Consent and best-interest decisions
seriousWhen people could not make certain decisions, the home did not consistently include the person's voice, family members, carers or health professionals in best-interest processes.
“People or their friends, families or representatives or health care professional had not been consulted when the person lacked capacity to make a decision, to ensure that the decision was in their best interests.” from the report
Weak management checks
seriousThe home's audits and monitoring systems failed to identify or resolve several important risks, including problems with infection control, recruitment and healthcare referrals.
“Quality monitoring systems and audits had failed to identify or address in a timely manner the concerns we found during the inspection.” from the report
Limited activities and personalisation
needs fixingCare plans were not always personalised, and inspectors did not see activities during the two inspection days. People were observed staying in their rooms for long periods.
“During the two days we were at the home we did not see any activities taking place and people were observed staying in their rooms for long periods.” from the report
- 01What changes have been made to infection control, PPE use, cleaning and isolation since the inspection?
- 02How are medicines, including drinks thickeners and refrigerated creams, now stored and checked?
- 03How do you make sure fire exits remain clear and that actions from fire risk assessments are completed promptly?
- 04How are families and health professionals involved in best-interest decisions when a person cannot make a decision themselves?
- 05What activities are now available, and how are care plans made more personal to each resident?
This was an unannounced inspection covering all five key questions, with specific concerns also examined about medicines and infection prevention and control. This explanation was written from the published report of 28 April 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 Bentley Court Care Home
10 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- October 2022Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2022Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2021Requires improvementSafe: GoodWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- November 2019Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- November 2019Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2019Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- December 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2021
Registered with the Care Quality Commission on 9 July 2021.
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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