CQC report explained · a nursing home
What the CQC found at Conifers Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2023
Requires Improvement; inspectors found risks, medicines, premises and management systems were not always safe or reliable.
This was an unannounced focused inspection on 13 and 15 September 2023. Inspectors spoke with people, relatives and staff, observed care, and checked care plans, medicine records, staff files and management records.
The home had enough staff and staff recruitment checks were completed. People were supported in line with the Mental Capacity Act, and inspectors found no evidence that anyone had been harmed. However, risks were not always managed safely, care plans were not always up to date, and medicines records and storage checks were inconsistent.
Some areas and equipment were unclean or worn, creating infection risks. Safeguarding processes needed strengthening. Quality checks did not reliably find or correct problems, and there was no registered manager in post at the time of the inspection.
The overall rating changed from Good at the previous inspection to Requires Improvement. The Safe and Well-led ratings were Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were used in the overall rating.
Enough staff
Inspectors found enough staff to support the people living in the home. Recruitment checks, including DBS checks, had been completed.
“There were enough members of staff to support the number of people living at Conifers Nursing Home.” from the report
Mental capacity rights
The home was working within the principles of the Mental Capacity Act. Necessary legal authorisations were in place where people were deprived of their liberty.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.” from the report
Improvement plans
The new manager and operations team had started reviewing care plans and described plans to improve the service. The management team was also working with the local authority.
“The management team had begun to review people's care planning documentation and we saw evidence of new care plans being compiled.” from the report
Personal protective equipment
Inspectors were assured that personal protective equipment was being used effectively and safely.
“We were assured that the provider was using PPE effectively and safely.” from the report
Risks and care plans
seriousSome risks were not managed safely and care plans did not always contain current information. Staff did not always follow information in care plans, which could put people's health and safety at risk.
“Some information contained in people's care plans was not always followed by staff which posed a risk to people's health and safety.” from the report
Medicines
seriousTemperature records and medicine stock records were inconsistent. Inspectors could not be assured that people received medicines as prescribed or that medicines would remain suitable for use.
“There were some medicines stock discrepancies which did not correlate with people's Medication Administration Records (MAR).” from the report
Cleanliness and equipment
seriousSome areas and equipment were unclean or worn, and a broken toilet was not marked as out of order. These issues created infection prevention and safety risks.
“Some areas of the premises and some equipment were unclean and posed an infection prevention control (IPC) risk.” from the report
Agency staff use
needs fixingThere had been high use of agency staff after staff turnover. Inspectors noted this could affect how consistent and caring support felt, although they found enough staff overall.
“Due to a recent turnover in staff, there was a high usage of agency staff.” from the report
- 01What changes have been made to ensure each person's care plan reflects their current health needs, including diabetes care?
- 02How are medicine temperatures, stock levels, administration times and blood glucose readings now checked?
- 03Which cleaning, equipment and repair problems identified by the inspection have been completed, including the broken toilet, worn equipment and broken windows?
- 04Who is currently responsible for management, and what is the progress of the new manager's registration application?
- 05How can residents, relatives and staff raise concerns, and how will the home show that feedback has been acted on?
This was a focused inspection of Safe and Well-led only, including infection prevention and control; the other three ratings were carried forward from the previous inspection. This explanation was written from the published report of 17 October 2023 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, September 2019
Rated Good overall, but inspectors found staffing concerns and medicines records that needed improvement.
This was an unannounced inspection on 27 August 2019. Inspectors spoke with people using the home, relatives, staff, the manager and provider. They reviewed care records, medicines records, complaints, safety and quality records, and recruitment records.
The home was rated Good overall. Effective, caring, responsive and well-led were rated Good. Safe was rated Requires Improvement, as some people and staff said there were not always enough staff and medicines stock records were incomplete.
Inspectors found people were generally safe, treated kindly and supported with personalised care. Risks were assessed, medicines were usually given as prescribed, staff were trained, and people received support with food, health needs, choices, activities and end of life care.
The previous overall rating was Requires Improvement. The safe rating stayed at Requires Improvement, while well-led improved from Requires Improvement to Good. The other Good ratings remained Good.
Kind and respectful care
Inspectors saw staff being kind and supportive. People said staff respected their privacy, dignity and individual preferences.
“We observed staff were kind and supportive when engaging with people.” from the report
Personalised support
Care plans recorded people's needs, choices and preferences. Staff could explain how individuals liked their care to be provided.
“Peoples care plans held details about their needs and preferences and these were reviewed and updated on a regular basis.” from the report
Good staff skills
Staff received induction, training and supervision. Inspectors observed staff using their knowledge of people's needs to provide effective support.
“Our observations confirmed staff were skilled and used their knowledge of people's needs to provide effective support.” from the report
Open management
The manager and provider carried out audits, responded to feedback and worked with health professionals and other agencies.
“The registered manager and provider regularly reviewed the quality of care people received.” from the report
Staffing levels
needs fixingPeople and relatives had mixed views about staffing. Staff said they were sometimes rushed, and people could have to wait longer than they should.
“The staff are good but there aren't enough of them for the work that has to be done. I'm kept waiting sometimes.” from the report
Incomplete medicines stock records
needs fixingMedicines were administered as prescribed, but changes to the records meant stock levels were not recorded. This made it harder to check accurately whether medicines had been given.
“This meant it was difficult for the provider to accurately check if people had received their medicine as there was no record of stock levels at the start of the month.” from the report
- 01What staffing levels are now in place, particularly at weekends, and how do you check that people are not waiting for care?
- 02What changes have been made to medicines records so stock levels are recorded and checked accurately?
- 03How will you show that the staffing and medicines concerns identified in this inspection have been fully addressed?
- 04How often are relatives' meetings now held, and how are actions from those meetings followed up?
This was an unannounced planned inspection that looked at all five key questions, the premises and the care provided. This explanation was written from the published report of 24 September 2019 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 Conifers Nursing Home
6 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- October 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2019Goodup from Requires improvementSafe: Requires improvementWell-led: Good
- September 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2017Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2017Inspected but not ratedSafe: Requires improvementResponsive: Requires improvement
- June 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- May 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 14 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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