CQC report explained · a nursing home
What the CQC found at Catherine Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments and care plans did not always lead to suitable action. Inspectors found gaps in falls prevention, fluid and nutrition support, repositioning records and choking precautions.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. People told inspectors staff were kind and that they were happy with their care.
- Responsive?
- Good
- This question was not inspected during this focused visit. The report records mixed feedback about food and activities.
- Well-led?
- Requires improvement
- Management oversight was not consistent. Records were sometimes incomplete or contradictory, audits did not identify all problems and communication with relatives had been poor.
What inspectors found, April 2021
Catherine Court rated Requires Improvement; inspectors found risks were not always managed and records and oversight needed to improve.
Inspectors visited on 09 March 2021. They spoke with people, relatives, staff and professionals, observed care and reviewed care plans, medicine records, accident records, infection control information and management records.
People said they were happy and felt safe. Inspectors found medicines were mostly managed safely, staffing levels were usually enough and staff were safely recruited. However, risks linked to falls, nutrition, fluids, pressure damage, behaviour and choking were not always managed properly.
The home also needed to improve infection control, record keeping, learning from incidents and management oversight. The registered manager had left, and an interim manager was leading the home. The overall rating fell from Good to Requires Improvement. This was a focused inspection of Safe and Well-led only. The other ratings were carried over from the previous inspection.
People felt safe and cared for
People told inspectors they were happy with their care and felt safe. Relatives were generally satisfied that family members received safe care.
“People told us they were happy with their care.” from the report
Staffing and recruitment systems
The rota usually showed enough staff to meet people's needs, and recruitment checks were completed. Call bells were answered promptly.
“Staff were suitably recruited. They completed an application form, were interviewed and pre employment checks were carried out.” from the report
Partnership working
The home worked with health and social care professionals, including diabetes specialists and the GP practice during the Covid-19 vaccination programme.
“Evidence showed good working with health and social care professionals.” from the report
Risks were not always controlled
seriousInspectors found that care plans and risk assessments did not always set out or deliver the action needed. This included risks from falls, poor nutrition, low fluid intake, pressure damage, behaviour and choking.
“Risks to people were not always mitigated. This was a breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Records and oversight were unreliable
seriousSome care records contradicted one another or were incomplete. Audits did not identify all problems, and the provider was slow to address some known failings.
“Records were not suitably maintained, and the provider did not have the oversight to ensure the quality and safety of the service provided.” from the report
Infection control needed improvement
needs fixingInspectors found problems with laundry arrangements, signage, storage and some staff clothing and mask use. These practices could increase the risk of cross-contamination.
“We were not assured that the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
Limited continuity from agency staffing
needs fixingThe home relied on agency nurses to cover rota gaps. Inspectors said this affected continuity of care and consistent management oversight.
“The home relied on agency staff, mainly registered nurses to cover shortfalls in the rota which impacted on continuity of care and consistent management oversight of the units.” from the report
Communication with relatives
needs fixingRelatives said communication from the home had been poor during the pandemic. The interim manager had started virtual family meetings and planned to hold them regularly.
“Relatives had received some communication from the provider and the service during the pandemic. However, they felt communication with the service had been poor.” from the report
- 01What specific changes have been made to prevent falls and ensure care plans are updated after an accident?
- 02How do you now monitor people's fluid and nutrition targets, and what happens when targets are repeatedly missed?
- 03How are repositioning records checked for people at high risk of pressure damage?
- 04What checks ensure the correct thickener and instructions are used for each person who needs drinks thickened?
- 05How many agency nurses are currently being used, and how are you maintaining continuity of care and management oversight?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous comprehensive inspection. This explanation was written from the published report of 22 April 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.
What inspectors found, November 2018
Rated Good; inspectors found kind, safe care, but medicines records and some end-of-life plans needed improvement.
Inspectors visited on 10 and 11 October 2018. The first day was unannounced. They spoke with people, relatives and staff, observed care, and checked care records, medicines, staffing, safety and management records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People and relatives generally said they felt safe and well cared for. Inspectors saw respectful care, suitable staffing, staff training, activities and systems for managing concerns.
There were two areas to improve. One person missed pain relief for a day because there was no stock, and some medicine records were not completed correctly. An end-of-life care plan was not in place promptly for one person. The inspectors made recommendations about both issues, but did not report any breached regulations.
Kind and respectful care
People and relatives gave positive feedback about staff. Inspectors observed good relationships and saw staff protecting people's dignity during personal care.
“People's dignity was protected and staff treated them with respect.” from the report
Suitable staffing and recruitment
Inspectors found staffing levels adequate for people's needs. Recruitment checks were in place, including Disclosure and Barring Service checks.
“Staffing levels ensured people received care when they needed it.” from the report
Trained staff
Staff completed induction, mandatory training and additional clinical training where needed. Supervision and appraisals were also in place.
“People were supported by staff with the relevant training.” from the report
Activities and social contact
The home offered group activities, one-to-one time, trips out and visits without restriction. This helped people take part in social activities and avoid isolation.
“People were able to take part in activities to avoid social isolation.” from the report
Medicine supply and records
needs fixingOne person did not receive pain relief for one day because there was no stock. Inspectors also found duplicate medicine charts and one unsigned record for additional insulin. These issues were corrected during the visit, and a recommendation was made about medicine management.
“We found one person had not been able to have their pain relief for one day due to lack of stock.” from the report
End-of-life care planning
needs fixingOne person receiving end-of-life care did not have an end-of-life care plan in place when inspectors checked. The manager said it was being completed, and inspectors recommended that such plans are completed promptly.
“We noted that the person did not have an end of life care plan in place.” from the report
- 01How do you check that each person's medicines are in stock and that every medicine administration record is complete?
- 02What changes have you made to prevent missed medicines, duplicate charts or unsigned records?
- 03How quickly will you complete an end-of-life care plan, and how will you involve the person and their family?
- 04How do you check that each person can reach their call bell or has another way to summon help?
- 05How will you keep us informed about care plan reviews, activities and any changes in our relative's needs?
This was an inspection of the overall service and all five key questions; the previous inspection in 2016 had also rated the home Good. This explanation was written from the published report of 22 November 2018 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 Catherine Court
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- April 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2018Goodstayed GoodSafe: GoodWell-led: Good
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 January 2011.
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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