CQC report explained · a nursing home
What the CQC found at Bentley House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Inspectors found medicine errors, inaccurate risk assessments, delays in some call-bell responses and safeguarding incidents that were not always reported as required. Infection prevention arrangements were followed.
- Effective?
- Good
- Staff had relevant induction, training and supervision. People were supported with nutrition, healthcare, communication, choice and least restrictive care.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff knew people well, supported independence and involved people in decisions about their care.
- Responsive?
- Good
- Care was personalised and adapted to people's preferences and changing needs. People were supported with activities, family contact, communication needs, complaints and end of life care.
- Well-led?
- Good
- Audits and incident reviews did not always identify risks or patterns, and some staff did not feel engaged with management. The provider responded with an improvement plan.
What inspectors found, January 2022
Bentley House was rated Requires Improvement; inspectors found kind, person-centred care but concerns about medicines, staffing, risk records and management oversight.
Inspectors carried out an unannounced planned inspection on 25 May 2021 and followed up with the provider on 11 June 2021. They spoke with people, relatives and staff, and checked care records, medicine records, recruitment files, incident reports and management records.
People generally said they felt safe and received kind, respectful and personalised care. Inspectors rated Effective, Caring and Responsive as Good. They found suitable training, support with food and healthcare, activities, family involvement and respectful care.
However, the home was not always safe. There had been medicine errors, including missed prescribed doses. Some risk assessments were inaccurate, people sometimes waited for call bells, and safeguarding concerns were not always reported to the local authority.
The overall rating was Requires Improvement. Safe and Well-led were rated Requires Improvement, meaning inspectors found limited assurance about safety and inconsistent management. The rating had fallen from Good at the previous inspection, published in October 2017.
Kind and respectful care
People and relatives spoke positively about the care. Staff promoted dignity, privacy, independence and choice.
“Staff had developed caring relationships with people.” from the report
Personalised support
Care records described people's individual needs and preferences. Staff could explain how people liked their care delivered.
“Care and support was personalised.” from the report
Staff training
New staff received induction and shadowing, and worked alone only after being assessed as competent. Staff also received regular supervision.
“Newly employed staff undertook a full induction which included training and shadowing experienced staff.” from the report
Food and healthcare
The home supported different dietary needs and worked with health professionals. People who needed extra help with nutrition were monitored and referred for support.
“People were happy with the quality of food provided.” from the report
Activities and family contact
People could take part in activities linked to their interests, spend time alone if they wished, and maintain contact with relatives during COVID-19 restrictions.
“Activity groups were organised that supported people's interests, such as gardening or cooking.” from the report
Missed medicines
seriousThere were increasing medicine errors in the three months before the inspection. Many April errors involved people not receiving prescribed medicines.
“Of the April 2021 errors, 27 of these were where people had not had their prescribed medicine administered.” from the report
Inaccurate risk assessments
seriousSome assessments gave conflicting or incorrect risk scores. This meant care might not have matched people's actual risks.
“The lack of accurate risk assessments meant people were at risk of receiving care that did not safely meet their assessed needs.” from the report
Call-bell delays and staffing concerns
needs fixingStaff said there were not enough staff and that people sometimes waited for support. Inspectors found some non-emergency call bells were not answered for more than 15 minutes.
“Staff however told us there were not enough staff to meet people's needs.” from the report
Safeguarding reporting
seriousManagers did not always refer incidents, including medicine errors and unexplained injuries, to the local authority when required.
“However, managers did not always report safeguarding incidents appropriately.” from the report
Weak management checks
needs fixingAudits and incident reviews did not consistently identify problems, trends or possible links between staffing and incidents. This limited assurance that the home was learning from events.
“Some lacked robustness as they had not picked up issues we found.” from the report
Staff communication and engagement
minorSome staff did not feel valued or connected to management. Care staff did not have regular face-to-face meetings during the period reviewed.
“Not all staff we spoke with felt engaged with the management team.” from the report
- 01How do you now prevent missed or incorrectly recorded medicines, and how are medicine errors reviewed with staff?
- 02How do you check that each person's nutrition, pressure injury and other risk assessments are accurate and consistent?
- 03What are the current staffing levels on each floor, and how do you monitor call-bell response times?
- 04How do you decide when an incident or unexplained injury must be reported as a safeguarding concern?
- 05What changes have been made to audits, incident reviews and meetings with care staff since this inspection?
This was an unannounced planned inspection covering all five CQC questions and infection prevention and control, with further evidence and provider feedback considered on 11 June 2021. This explanation was written from the published report of 19 January 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 House
Each visit the CQC has published, newest first, back to the day the home was registered.
- January 2022Goodcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2019
Registered with the Care Quality Commission on 6 November 2019.
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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What to check when you visit
At least 100 live-in carers within about an hour of Hertfordshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,300 a week. 82 can care for a couple. 12 years' experience on average.
“She handled the new situation in front of her with such professionalism and I felt I could trust her 100%.”
“She was v competent and confident and we felt our mum was safe in her care. She supported us through a difficult time.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.