CQC report explained · a nursing home
What the CQC found at Carisbrooke Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found risks were assessed and medicines were generally managed safely. However, some fire safety checks were not recorded, several staff did not wear face masks correctly, and individual PRN medicine protocols were not in place.
- Effective?
- Good
- People received appropriate food, drink and healthcare, and staff understood consent and best-interest decisions. Staff had induction and training, but supervision was not completed consistently and there were some training gaps.
- Caring?
- Good
- People were treated with kindness, dignity and respect. They were involved in decisions about their care, and staff knew their preferences.
- Responsive?
- Requires improvement
- Care plans were detailed and included people’s communication needs, preferences and healthcare advice. However, people did not have enough opportunities to take part in activities or spend time in communal and outdoor areas.
- Well-led?
- Requires improvement
- The home had management systems and some useful audits, but these did not identify or address important shortfalls quickly enough. Communication and staff meetings were inconsistent, and CQC was not notified that the registered manager had been absent for more than 28 days.
What inspectors found, September 2022
Rated Requires Improvement; inspectors found kind, effective care, but social activities, management oversight and some safety checks were not reliable enough.
This was the home’s first inspection. It was unannounced and took place on 13 July 2022 and 03 August 2022. Inspectors spoke with people, relatives and staff, and checked care records, medicines, staff files and management records.
People generally said they felt safe and were treated kindly. Inspectors found good care around food and drink, healthcare, consent, dignity, privacy, medicines and personalised care planning. The ratings for Effective and Caring were Good.
However, people’s emotional and social needs were not consistently met because there was no planned programme of activities or dedicated activities support. Fire safety records, PPE use, staff supervision and management communication also needed improvement.
The overall rating was Requires Improvement. The Safe, Responsive and Well-led ratings were Requires Improvement. The provider was required to send an action plan, and CQC said it would monitor progress with the provider and local authority.
Kind and respectful staff
People told inspectors that staff were kind, friendly and respectful. Inspectors observed positive interactions and found that staff knew people well.
“People told us they were well cared for, and staff were kind, friendly and good humoured.” from the report
Personalised care planning
Care plans included people’s routines, likes, dislikes, cultural needs and preferred way of receiving support. They were kept up to date with changes from health professionals.
“We saw people's needs were assessed, and detailed person-centred care plans and risk assessments were in place to guide staff on how people liked their support to be provided.” from the report
Food and healthcare
People said they enjoyed the food and had enough to eat. Staff monitored nutrition and sought healthcare advice when people’s needs changed.
“People told us they enjoyed the food and had enough to eat.” from the report
Dignity and privacy
Inspectors saw staff knock before entering rooms and protect people’s privacy during personal care. People were addressed by their preferred names and were appropriately dressed.
“We saw staff knocking on peoples' doors before entering and bedroom doors were closed whilst people were having their personal care needs tended to.” from the report
Very few activities
seriousPeople’s social and emotional needs were not met consistently. There was no weekly activities programme and no staff member dedicated to providing activities or one-to-one time.
“People told us they did not have the opportunity to take part in activities and they were left to entertain themselves.” from the report
Weak management oversight
seriousThe quality checks did not identify or deal with several problems quickly enough. The registered manager had been absent for months and CQC had not been notified as required.
“The governance systems were not robust enough to identify and address shortfalls we found during this inspection.” from the report
Fire safety records
needs fixingThe home had some safety checks, but records did not show that fire extinguishers were checked regularly or that staff took part in regular fire drills.
“Whilst some fire safety checks were completed, records did not demonstrate fire extinguishers were checked regularly or staff had received regular fire drills.” from the report
PPE practice
needs fixingInspectors saw several staff wearing face masks incorrectly in shared areas and corridors. The provider acted during the inspection, but CQC recommended further action.
“We were only somewhat assured about staff use of personal protective equipment (PPE).” from the report
Staff support and communication
needs fixingStaff supervision had not been completed consistently. Staff also said management communication and staff meetings were not regular enough.
“Staff told us that communication from the management was not always good and meetings had not taken place consistently since the provider had taken over the running of the service.” from the report
- 01What regular activities and one-to-one support are now available, and how do you record people’s participation?
- 02What fire safety checks and staff fire drills have been completed since the inspection?
- 03How do you check that staff wear PPE correctly in communal areas and corridors?
- 04How often do staff now receive supervision, and how are training gaps monitored?
- 05Who is currently responsible for managing the home, and how do you keep families informed about management and staff meetings?
This was the first unannounced inspection of the home and covered all five CQC questions, including infection prevention and control, the premises and the care provided. This explanation was written from the published report of 13 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.
What inspectors found, February 2021
Inspected but not rated; inspectors were assured that infection control measures were in place to help protect people from COVID-19.
The CQC made an unannounced visit on 15 January 2021. This was a targeted inspection during the coronavirus pandemic. It looked at infection prevention and control in the home.
Inspectors found measures for safe visiting, testing, hand washing, temperature checks and personal protective equipment. Staff had infection control training, and there were sufficient supplies of protective equipment.
The home was clean and hygienic, with cleaning schedules for frequently touched surfaces. Inspectors were assured about infection control, but the service was not given an overall rating or a rated assessment of all five areas of care.
Infection control systems
The home had systems and updated policies to help prevent and manage COVID-19 infections.
“Robust systems were in place to help manage the risks and prevent the spread of COVID-19.” from the report
Safe visiting arrangements
Visitors were limited to essential visits and had to complete safety checks before entering the main part of the building.
“On arrival visitors were asked to consent to a lateral flow test, have their temperature checked, wear personal protective equipment (PPE), and wash their hands before they would be allowed to enter the main part of the building.” from the report
Protective equipment and training
Staff had training in infection control and using protective equipment. Inspectors saw staff using it correctly, and supplies were available.
“Staff had received training in infection prevention and control and the use of PPE including masks, gloves, aprons and hand sanitiser.” from the report
Clean environment
Inspectors found the premises clean and hygienic, with cleaning schedules covering frequently touched surfaces and equipment.
“The premises looked clean and hygienic and there were effective cleaning schedules in place, including cleaning of high touch surfaces such as, handles, light switches and frequently touched equipment.” from the report
Inspectors raised no specific concerns in this report.
- 01How are the infection prevention and control arrangements described in this report being maintained now?
- 02What are the current rules for visiting, including testing, protective equipment and hand washing?
- 03How do you support residents to keep in touch with relatives if visits are restricted?
- 04How often are high-touch surfaces and frequently touched equipment cleaned?
- 05What happens if there is an infection outbreak in the home?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; the service was inspected but not rated overall. This explanation was written from the published report of 12 February 2021 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 Carisbrooke Nursing Home
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- September 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2021Inspected but not ratedSafe: Inspected but not rated
- March 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2020
Registered with the Care Quality Commission on 5 November 2020.
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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