CQC report explained · a nursing home
What the CQC found at Cow Lees Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, July 2023
Rated Requires Improvement; inspectors found progress, but ongoing risks in care records, restrictions, infection control and oversight.
This was an unannounced focused inspection on 13 and 15 June 2023. Four inspectors and a specialist nurse adviser visited, while one inspector spoke with relatives by telephone. They reviewed care plans, medicines records, incidents, staff files, training records and quality checks.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were all rated Requires Improvement. Inspectors found that some improvements had been made, including safer medicines management, enough staff, safer recruitment and better contact with health professionals.
However, important problems remained. Risk records did not always give staff enough guidance, the use of physical restraint was not properly monitored, some areas were dirty, and some restrictions were not supported by clear mental capacity and best-interests records. Quality checks had been introduced but did not always lead to action.
The home had been rated Requires Improvement at the previous inspection and has held this rating for three consecutive inspections. The provider had previously received a Warning Notice and completed an action plan. CQC said the home remained in breach of Regulations 11, 12 and 17.
Enough staff
Inspectors found there were enough staff to provide safe care. Staff said staffing levels allowed them to respond to people's needs.
“There were enough staff to provide safe care.” from the report
Safer medicines
Some medicines systems had improved, including the use of patches and the management of insulin-dependent diabetes. Medicines were also reviewed with other health professionals.
“At this inspection, some improvements had been made. Patch medicines were administered safely and the management of people with insulin dependent diabetes had improved.” from the report
Positive staff feedback
Relatives spoke positively about staff's skills, kindness and understanding of dementia. Some said their relatives looked healthier after moving to the home.
“Staff seem to understand people with dementia. They go through photos of objects with [person] to prompt their memory.” from the report
Partnership working
The home worked with health professionals and other agencies to review medicines and improve people's health outcomes.
“The registered manager and staff worked closely with external health professionals and agencies, in response to people's changing needs and to improve their health outcomes.” from the report
Food and drink support
Relatives said people had gained weight and looked healthier. Staff encouraged people to drink regularly, especially in hot weather, and offered choices about meals.
“People were given visual choices about the meals they wanted shortly before the meals were served.” from the report
Risk records and restraint
seriousCare plans did not always explain how to respond to distress, seizures or other risks. Inspectors also saw physical intervention used in circumstances where they could not be sure it was the least restrictive option.
“There was limited oversight of the use of restrictive physical intervention to ensure this was used appropriately, and to reduce the need to use these techniques again in the future.” from the report
Infection control and cleanliness
seriousSome shared kitchens, bathrooms and toilets were visibly dirty and had unpleasant smells. Some equipment could not be cleaned effectively, and food hygiene practices were not always followed.
“Some areas of the home including shared kitchens, bathrooms and toilets were visibly dirty and there were unpleasant odours in certain areas of the home.” from the report
Mental capacity and restrictions
seriousThe home did not always record whether people had consented to restrictions or whether decisions had been made in their best interests. Some people could not freely access their bedrooms because doors were locked.
“There were no records to evidence this restriction had been assessed as being in people's best interests.” from the report
Quality checks not effective
seriousAudits sometimes identified problems without ensuring they were fixed. For example, a damaged mattress was repeatedly recorded as needing replacement but had not been replaced.
“Every monthly audit since then had identified the same issue, but no action had been taken.” from the report
As-required medicines
needs fixingRecords did not explain why some medicines for agitation were given or whether they worked. Protocols also lacked clear instructions about alternatives to try first.
“There was no explanation for the reason for administration, or record of the effectiveness, documented on the back of the medicine administration record (MAR).” from the report
Training oversight
needs fixingStaff received a range of training, including specialist training, but inspectors said more monitoring was needed to check that training was effective in practice.
“However, additional monitoring and oversight was needed to ensure staff training was effective.” from the report
- 01How have you updated care plans to explain how staff should manage seizures, distress and other individual risks?
- 02How do you record, review and reduce the use of physical intervention, and how do you make sure it is only used as a last resort?
- 03What has been done to improve cleanliness, equipment repairs, food hygiene and the safe storage of chemicals?
- 04How do you make sure locked bedroom doors and other restrictions are supported by decision-specific capacity assessments and best-interests decisions?
- 05What evidence can you show that the problems identified by audits are now fixed and checked again?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 21 July 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, July 2022
Rated Requires Improvement; inspectors found risks in medicines, health monitoring and governance, with legal breaches.
This was an unannounced inspection on 18 May 2022, followed by an announced visit on 20 May 2022. Inspectors reviewed care plans, medicines records, recruitment files and management records. They also spoke with people, relatives and staff, and observed care.
The home was not always safe. Inspectors found problems with monitoring diabetes, fluid intake and pressure sores. Medicines were not always stored or given safely. Some areas and furniture were not clean, and some environmental risks had not been dealt with.
Care was not always effective or well managed. People with dementia were not always shown visual food choices, and some bedroom doors were locked so people could not enter without staff. The home had positive features, including enough staff, specialist healthcare support and approachable managers. However, the overall rating remains Requires Improvement, as it did at the previous inspection.
Staffing and recruitment
Inspectors found that staff were recruited safely and that there were enough staff to support people. Relatives and staff also gave positive feedback about staffing levels.
“Staff were recruited safely. Recruitment processes included background checks to assure the provider of the suitability of staff to work at the home.” from the report
Healthcare support
People received support from specialist healthcare professionals, including services for wounds, foot care and nutrition. Records of healthcare visits were kept.
“People received specialist external support from healthcare professionals including tissue viability nurses, chiropodists and dieticians.” from the report
Supportive management
Relatives and staff described managers as approachable and supportive. Staff said managers listened to concerns and supported their development.
“Staff also gave positive feedback about working at the home, being supported and the workplace culture.” from the report
Outdoor areas
People could use gardens, patios and a conservatory. Inspectors saw some people enjoying time outside with staff.
“People had access to a range of outside spaces including large garden areas, patios and a conservatory.” from the report
Health risks were missed
seriousA person with diabetes had frequent very high blood glucose readings, but no action was taken to request an urgent medical review. Records for fluid intake and pressure sore care were also incomplete.
“No action was taken in response to those readings. We gave feedback on this concern during our inspection and in response, an urgent diabetic review was requested.” from the report
Medicines were not always safe
seriousSome medicines were missed, given at the wrong time or without the required instructions. Records for pain-relief patches did not show safe site rotation and checks.
“Medicines were not always stored or administered safely.” from the report
Infection control problems
seriousSome areas and furniture were visibly dirty. Inspectors also found sticky flooring, an unsafe position for a protective equipment bin and some incorrect mask use.
“Some infection prevention and control risks had not been identified. On the first day of our inspection, areas of the home and some upholstered furniture were visibly dirty and not clean.” from the report
Weak management checks
seriousThe home's systems did not identify several care, medicine, infection control and premises risks. Four serious injuries had not been reported to CQC as required.
“Some incidents were not reported to us as per regulatory requirements. We identified four serious injuries which had not been notified.” from the report
Limited personal choice
needs fixingPeople with dementia were not always shown visual meal choices. In some areas, bedroom doors were locked, so people could not enter their rooms without staff support.
“People were not always offered choices about where they spent their time.” from the report
- 01How are you now responding to very high blood glucose readings, and when would you request an urgent medical review?
- 02How do you check that medicines, including pain-relief patches, are given at the correct time and according to their instructions?
- 03What checks now confirm that shared areas, furniture, food trolleys and protective equipment arrangements are clean and safe?
- 04How are pressure sores, fluid intake and urinary tract infection risks recorded and reviewed?
- 05What evidence can you show that the Regulation 12 and Regulation 17 warning notices have been addressed and that improvements are being maintained?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 20 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.
Every inspection of Cow Lees Care Home
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2022Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- February 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- April 2013
Registered with the Care Quality Commission on 10 April 2013.
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 Warwickshire
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 £950 to £1,260 a week. 77 can care for a couple. 11 years' experience on average.
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