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
- There had been many medicines errors, including missed doses, and some risk assessments were inaccurate. Safeguarding concerns were not always referred to the local authority as required.
- Effective?
- Good
- Staff had relevant training and supervision. People received support with nutrition, hydration and healthcare, and the home worked with health professionals.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff knew people well and supported their independence, choices and cultural needs.
- Responsive?
- Good
- Care plans were personalised and reflected people's needs and preferences. People were supported with activities, relationships, communication and end of life care.
- Well-led?
- Good
- Managers were open to feedback and created an improvement plan. However, audits did not always identify patterns in medicines errors, falls, incidents or safeguarding concerns, and some staff did not feel engaged with management.
What inspectors found, July 2022
Rated Good overall, but inspectors found medicines, risk assessments and safeguarding systems were not always safe.
Inspectors visited the home without notice on 25 May 2021 and followed up on 11 June 2021. They spoke with people, relatives and staff, and checked care, medicines, incidents, recruitment and management records.
The overall rating was Good. Effective, Caring, Responsive and Well-led were rated Good. Safe was rated Requires Improvement, meaning there was limited assurance that people were always protected from avoidable harm.
Inspectors found kind and personalised care, good support with food and healthcare, and activities to reduce isolation. However, there had been many medicines errors, some risk assessments were inaccurate, and some safeguarding concerns were not reported as required.
The home produced an action plan and took steps during and after the inspection to address the concerns. CQC said it would monitor progress and return under its re-inspection programme.
Kind and respectful care
People and relatives described staff as kind and caring. Staff respected privacy, dignity, choices and independence.
“People were supported kind and caring staff who they trusted.” from the report
Personalised support
Care records described people's personal needs and preferences. Staff could explain how individuals liked their care to be provided.
“Care and support was personalised.” from the report
Food and nutrition
The home met individual dietary needs and used creative approaches for people on pureed diets. People were happy with the food.
“People's individual preferences were met and they were supported to maintain a balanced diet.” from the report
Activities and relationships
People could join activities linked to their interests, spend time alone if they wished, and receive one-to-one support when needed.
“Activity groups were organised that supported people's interests, such as gardening or cooking.” from the report
Infection control
Inspectors found appropriate COVID-19 precautions, including testing, distancing and supplies of protective equipment.
“Staff told us they had enough supply of PPE and were regularly tested for COVID-19.” from the report
Missed medicines
seriousThere had been a rising number of medicines errors before the inspection. Many 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 assessment tools gave conflicting or incorrect risk scores. This meant care might not have safely matched people's assessed needs.
“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
Safeguarding referrals
seriousSome incidents involving medicine errors, unexplained bruising or injury were not always referred to the local authority as required.
“However, managers did not always report safeguarding incidents appropriately.” from the report
Management checks
needs fixingAudits and reviews did not always look for patterns in medicines errors, falls, incidents or safeguarding concerns.
“Analysis of themes and trends around incidents, injuries or safeguarding was not robust.” from the report
Staff communication
minorSome staff did not feel valued, informed or connected to the management team. Regular face-to-face meetings for care staff had not restarted.
“Staff told us they did not feel informed or connected to the management team throughout this period.” from the report
- 01What changes have been made to prevent missed or incorrectly recorded medicines since April 2021?
- 02How are risk assessments now checked for accuracy, especially for nutrition and pressure injuries?
- 03How do you decide whether an incident must be referred as a safeguarding concern, and can you show how this is audited?
- 04What staffing levels are currently in place, and how do you respond when staff report that people are waiting for care?
- 05How are care staff now kept informed and given regular opportunities to raise concerns with managers?
This was an unannounced planned inspection covering all five key questions and infection prevention and control; the inspection visit took place on 25 May 2021, with follow-up and feedback on 11 June 2021. This explanation was written from the published report of 13 July 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, October 2017
Rated Good; inspectors found safe, kind and personalised care, with effective management systems.
The inspection took place on 19 September 2017. One inspector observed care, reviewed records and spoke with people living at the home, a relative, staff and a visiting health professional.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and had enough staff to help them. Inspectors found medicines were managed safely, staff were trained, and people received suitable food and healthcare.
Inspectors found that staff knew people's preferences and provided personalised care. People were involved in care decisions, supported to remain independent and offered activities suited to their interests.
The home had improved areas that had previously needed work. A focused inspection in December 2016 found those areas had become Good, and inspectors found they remained Good at this inspection.
Safe medicines
Medicines were given by trained staff whose competence was checked. Records and medicine amounts matched during the inspection.
“We found that medicine administration records (MAR) were completed accurately and signed by staff each time after they administered people`s medicines.” from the report
Personalised care
Staff knew people's likes, dislikes and preferences. Care was adapted to support people's choices and independence.
“People's choices, likes, dislikes and preferences were well known to staff who delivered care and support in a personalised way.” from the report
Activities and interests
The home offered activities tailored to people's needs and interests, including outings, hobbies and opportunities to share skills.
“We found that activities were tailored to people`s needs and likes and included as much group activities and individual activities as well.” from the report
Effective oversight
The manager and provider used audits and feedback to find shortfalls and act on them promptly.
“There were robust and effective systems in place to assess, monitor and review the quality of service provided.” from the report
Inspectors raised no specific concerns in this report.
- 01What is the current position on the manager's CQC registration?
- 02Which people had Deprivation of Liberty Safeguards applications awaiting authorisation, and what is their current status?
- 03How will you make sure care plans are updated promptly when a person's needs change?
- 04How do you check that staffing levels remain sufficient for people's needs at different times of day?
- 05Which activities are available for someone with my relative's interests, abilities and health needs?
This inspection considered all five CQC questions and found that the previous improvements in Safe and Well-led remained Good. This explanation was written from the published report of 12 October 2017 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
5 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- July 2022Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2017Goodup from Requires improvementSafe: GoodWell-led: Good
- August 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2016Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2015
Registered with the Care Quality Commission on 26 January 2015.
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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