CQC report explained · a nursing home
What the CQC found at Court House Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2023
Rated Requires Improvement; inspectors found risks with medicines, staffing, care records, infection control and management oversight.
Inspectors visited the home on 15 and 20 February 2023. They spoke with people, relatives, staff and visiting professionals, and reviewed care records, risk assessments, medicine records, training and management checks. The inspection was prompted partly by concerns about staffing, medicines, infection control and management oversight.
The overall rating and all five question ratings were Requires Improvement. Inspectors found people were not always protected from harm. Medicines were not always managed safely, risks were not consistently assessed, staffing levels were not based on an evidence-based tool, and infection control practices needed improvement.
Care plans and records were not always up to date, and staff did not always have the training or guidance needed for people's health needs. People and relatives were not always involved in care planning, and some people did not receive enough activities or support with personal choices. Inspectors did find caring interactions, some meaningful activities, systems for complaints and some partnership working with health professionals.
The provider took some immediate actions after the inspection, including changes to insulin records and training, safer storage of thickener, and updates to emergency evacuation plans. CQC issued warning notices for safe care and treatment and good governance, and said it would monitor an action plan.
Some caring interactions
Inspectors saw calm and caring interactions in communal areas. Some people and relatives also said staff were kind and knew people well.
“We observed calm and caring interactions from staff towards people in communal areas.” from the report
Complaints and feedback systems
The home had a complaints policy and a system for reviewing complaints. Meetings and questionnaires were also used to gather views.
“The provider had a complaints policy and the registered manager had a system for reviewing complaints and responding to concerns.” from the report
Some meaningful activities
Some people were supported with meaningful activities, although this was not consistent across the home, especially for people cared for in their bedrooms.
“However, some people were supported with a range of meaningful activities and staff were attentive to people's emotional and social needs.” from the report
Partnership working
Staff worked with health and social care professionals, including GPs and specialist services, to help meet people's needs.
“Staff worked with other health and social care professionals, such as people's GPs, tissue viability and falls specialists, and social workers” from the report
Medicine errors
seriousMedicine records were not always accurate. Two people were not supported to take insulin as prescribed, with several wrong doses recorded, creating a significant risk of harm.
“We found 2 people were not supported to take their Insulin as prescribed and there were several instances where they were given the wrong dose.” from the report
Risks not properly managed
seriousRisks such as choking, dehydration, pressure damage and diabetes did not always have clear staff guidance. Some unsafe areas were left unlocked and thickener was stored insecurely.
“Risks to people had not always been effectively assessed and managed. This was a breach of regulation 12 (Safe care and treatment)” from the report
Staffing pressures
needs fixingPeople and relatives reported delays, fewer baths and fewer walks. The provider was not using an evidence-based tool to check whether staffing levels met people's needs.
“The provider did not use an evidence-based tool to determine staffing levels in accordance with people's needs and the environment.” from the report
Infection control
seriousInspectors found clutter, unsafe mask use and a risk of cross-infection during a COVID-19 outbreak. Infection-control procedures did not consistently protect people.
“Infection control procedures did not consistently protect people from the risk of infection. This was a breach of Regulation 12” from the report
Care was not always person-centred
needs fixingPeople and relatives were not always involved in care plans. Bathing was organised around a rota, and some people did not receive enough activities or help with communication.
“People and their relatives were not always involved in the development and reviewing of their care plans.” from the report
Weak management checks
seriousAudits did not identify important problems in records, medicines, risks and infection control. The provider also failed to send some required notifications to CQC.
“The lack of effective quality assurance systems, processes and audits meant management and staff did not have a shared understanding of challenges, concerns and risks” from the report
- 01What has changed since the inspection to prevent medicine errors, particularly wrong insulin doses?
- 02How do you now assess staffing levels against people's needs, and how do you prevent delays with bathing, walks and personal care?
- 03How are care plans and risk assessments checked and updated when a person's needs change?
- 04What measures are now in place to keep thickener, cleaning cupboards and other environmental hazards safe?
- 05How are you checking that the warning notices and action plan have been fully addressed?
This was an unannounced full inspection covering all five key questions, with visits on 15 and 20 February 2023 and additional telephone feedback from relatives. This explanation was written from the published report of 30 June 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.
Every inspection of Court House Care Home
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- June 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2020Goodstayed GoodSafe: GoodWell-led: Good
- January 2020Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2022
Registered with the Care Quality Commission on 8 February 2022.
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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At least 100 live-in carers within about an hour of Worcestershire
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 £1,260 a week. 85 can care for a couple. 9 years' experience on average.
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
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.