CQC report explained · a residential care home
What the CQC found at Delph House
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 gaps in risk assessments, repositioning records, safeguarding reporting and staff ability to recognise deteriorating health. Medicines were mostly well managed, and infection control arrangements were generally satisfactory.
- Effective?
- Good
- This question was not assessed during this focused inspection. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This question was not assessed during this focused inspection. The report records broadly positive feedback about the kindness of staff.
- Responsive?
- Good
- This question was not assessed during this focused inspection. Its previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Inspectors found weak oversight of safeguarding, gaps in care records and audits that did not always identify problems. Leadership had improved from the previous Inadequate rating, but management remained inconsistent.
What inspectors found, October 2023
Requires Improvement overall for the third consecutive inspection; inspectors found improvements but ongoing concerns about risk management, safeguarding, staffing skills and oversight.
This was an unannounced focused inspection. Inspectors visited on 11 April, 14 April and 31 May 2023. They spoke with people using the home, relatives, staff and health professionals. They also checked care plans, medicines records, staffing information and safety records.
The home had improved in several areas, including the environment, medicines management and its approach to infection prevention. However, inspectors found that some risks were not properly assessed or reduced. Staff did not always recognise when people's health was getting worse, and safeguarding incidents had not always been reported to the CQC or the police when needed.
The overall rating was Requires Improvement. Safe and Well-led were both rated Requires Improvement. This was the third consecutive inspection with that overall rating. The home remained in breach of regulations about safe care and treatment, good governance and notifying the CQC about incidents.
Improved environment
Environmental risks were mostly better managed than at the previous inspection. The home was undergoing refurbishment and safety systems were regularly tested.
“Risks relating to the environment were mostly well managed and much improved from our last inspection.” from the report
Medicines mostly managed well
Staff had medicines training and showed a good understanding of medicines that had to be given at particular times. There was one stock control discrepancy.
“Medicines were well managed, and records were mostly accurate.” from the report
Kind staff
People and relatives gave broadly positive feedback about the care. Relatives described staff as kind and said they were usually informed about falls or changes.
“People using the service and relatives gave us broadly positive feedback about the care and support provided.” from the report
Clean communal areas
Inspectors found the home clean, with no unpleasant smells in communal areas. They were also assured about the use of protective equipment and infection outbreak arrangements.
“The service was clean and there were no unpleasant odours in any communal areas.” from the report
Risks were not always controlled
seriousSome risks, including supervision, repositioning, topical creams and use of the main staircase, were not fully assessed or reduced. Inspectors could not be fully assured that repositioning always followed people's risk assessments.
“The provider had failed to ensure people always received safe care and treatment.” from the report
Safeguarding reporting failures
seriousSeveral safeguarding incidents had not been reported to the CQC without delay. One incident had not been referred to the police even though the person involved had asked for this.
“The provider had failed to submit required notifications.” from the report
Staff skills and communication
seriousSome staff did not have enough confidence, spoken English or understanding to recognise and respond promptly when people's health changed. Further training and careful monitoring were needed.
“They told us staff did not always recognise and act promptly when a person's health was deteriorating or their needs changing.” from the report
Staff were not always visible
needs fixingStaff were sometimes gathered in the staff room, leaving upstairs and communal areas without staff for periods. This had also been found at the previous inspection.
“We identified staff were occasionally gathering in the staff room on the ground floor, leaving the upstairs and communal areas unstaffed for periods of time.” from the report
Weak management checks
needs fixingAudits did not always identify problems, including unsafe fridge, freezer and water temperatures. Care records also contained gaps and inconsistencies.
“Although we noted a wider scope of audits was now in place not all the issues we raised had been identified by the provider's own processes.” from the report
- 01What has changed to make sure all safeguarding incidents are reported to the CQC and referred to the police when required?
- 02How do you check that staff can recognise and respond quickly when someone's health deteriorates?
- 03How are staff deployed now so that upstairs and communal areas are not left without staff?
- 04What action has been taken to assess and reduce risks linked to the main staircase, topical creams and repositioning?
- 05How do your current audits identify and correct problems such as unsafe temperatures and gaps in care records?
This was an unannounced focused inspection of Safe and Well-led; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 5 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, March 2022
Requires Improvement overall; inspectors found safety shortfalls and rated the home's leadership Inadequate.
This was an unannounced focused inspection on 15 December 2021. Inspectors checked whether the home had acted on its previous improvement plan. They spoke with people living there, relatives, staff and a health professional, and reviewed care records, medicines records, staff files and management records.
Some improvements had been made. The home looked clean and more homely, damaged equipment had been removed, and a secure garden was being developed. Staff recruitment checks and training were in place. Infection control arrangements and COVID-19 vaccination checks had improved.
However, care plans and daily records did not always explain or show the support people received. Inspectors found gaps in managing falls, safeguarding concerns, repositioning, mobility, oral care and medicines. They were also concerned that people were not always involved or informed about their care.
The overall rating stayed at Requires Improvement. Safe was rated Requires Improvement, while Well-led fell from Requires Improvement to Inadequate. The other three question ratings were not inspected and were carried forward from the previous inspection.
Improved environment
The home had made progress with its environment. It had new carpets, redecoration and some replacement furniture, and damaged equipment had been removed.
“The environment had received many improvements since our last inspection. This included new carpets, redecoration and some furniture had been replaced.” from the report
Recruitment checks
Inspectors found that staff recruitment included checks on previous employment and suitability.
“Staff were safely recruited, and checks were made on their character from previous employers and on their suitability through the Disclosure and Barring Service (DBS).” from the report
Infection control progress
The home had improved its infection control arrangements and had effective measures for COVID-19 vaccination requirements.
“We found the service had effective measures in place to make sure this requirement was being met.” from the report
Staff training
Staff had completed training and competency checks for moving and handling and medicines.
“Regular training competencies were completed for staff in relation to moving and handling and medication to ensure staff had the correct skills to keep people safe.” from the report
Incomplete risk information
seriousCare plans did not always explain how to keep people safe, including when moving between floors, using bed rails or being repositioned. Daily records also did not clearly show the support people received.
“The provider had failed to robustly assess the risks relating to the health safety and welfare of people.” from the report
Safeguarding and falls follow-up
seriousThe provider did not have a clear overview of safeguarding concerns raised by external bodies. Inspectors also found no evidence that the falls team had been updated after one person had three falls in a month.
“We were not assured all safeguarding's had been appropriately acted upon to keep people safe.” from the report
Medicines process
seriousA medicated patch was not being applied according to the manufacturer's instructions. The record was changed during the inspection.
“Medicated patches were not being applied as per manufactures instructions causing a risk of potential harm to the person.” from the report
Limited involvement
needs fixingPeople were not always told what staff were doing during care. The lounge was sometimes left without staff supervision, and regular meetings for people had not been maintained.
“People were not engaged or informed what support the staff were completing.” from the report
Limited meaningful activity
needs fixingStaff were described as task-focused, with little meaningful activity observed. People were seen sitting with their heads in their hands, and only brief singing was observed.
“Staff were offering task based support and there was a lack of meaningful activity.” from the report
- 01How do you now check that each person's care plan clearly explains their risks, mobility needs, repositioning and bed rail requirements?
- 02What has changed in the way you record and follow up falls and safeguarding concerns?
- 03How do you check that medicines, including medicated patches, are given exactly as prescribed?
- 04Who is currently responsible for managing the home, and how do you make sure relatives and health professionals know whom to contact?
- 05How are people now involved in decisions about their care, communication preferences and daily activities?
This was an unannounced focused inspection of Safe and Well-led only; the other three key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 9 March 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 Delph House
6 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- October 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Inadequate
- May 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- August 2019Goodstayed GoodSafe: GoodWell-led: Good
- November 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2015
Registered with the Care Quality Commission on 10 April 2015.
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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