CQC report explained · a nursing home
What the CQC found at Delves Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2023
Rated Requires Improvement; inspectors found serious shortfalls in staffing, safety, choice, personalised care and management.
This was the first inspection since the home registered. It was unannounced and took place on 9 and 10 January 2023. Inspectors spoke with people, relatives, staff and professionals, reviewed care and medicine records, and observed care.
The home was not always safe. Staffing levels were not reliable, registered nurses were not always available, and people sometimes waited for care. Inspectors also found problems with medicines, wound care, nutrition, infection control and investigating incidents.
All five areas were rated Requires Improvement. People often described kind staff, good activities and positive support from managers, but care was not consistently safe, respectful, personalised or well managed. The inspection found five legal breaches, and the provider was required to make changes.
Kind support when people were distressed
Inspectors saw staff respond calmly and compassionately to people who were upset or agitated.
“Staff were compassionate and patient when supporting people who were displaying behaviour of agitation or distress.” from the report
Activities and social support
People were offered group and individual activities based on their interests. Inspectors saw people enjoying activities, including one-to-one activities for people cared for in bed.
“People were supported with individual and group activities.” from the report
Food choices and specialist diets
People said they enjoyed the food, could get drinks, and were offered alternatives. Staff understood how to modify meals for choking risks.
“People who didn't like the meal options available were offered alternatives.” from the report
Access to healthcare
People and relatives said healthcare support was available when needed. Professionals said the home responded to advice and sought outside support.
“People and relatives said people were supported to access healthcare services as needed.” from the report
Complaints and feedback
The home had systems to record and respond to complaints. Inspectors saw that issues raised had been explored and addressed.
“The provider had a system in place to record, investigate and respond to complaints received.” from the report
Not enough reliable staffing
seriousThe staffing calculation system was unreliable. People sometimes waited for personal care or support, and inspectors intervened when no staff were available during an incident between two people.
“There was a failure to ensure sufficient numbers of suitably qualified staff were deployed to meet people's needs.” from the report
Unsafe care systems
seriousInspectors found problems with medicines, supplements, wound care, weight loss and infection outbreak reporting. These failures placed people at risk of harm.
“Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
People's rights and choices
seriousThe home did not always check people's capacity or best interests when restrictions or cultural and religious choices were involved. One required liberty safeguard had not been requested.
“The provider had failed to ensure people's rights were protected.” from the report
Care was not always personalised
seriousSome people were not given enough choice about when to get up. Continence support and the way medication was given did not always reflect individual needs or privacy.
“The provider had failed to ensure people had maximum choice and control over their needs and preferences.” from the report
Weak management checks
seriousAudits had not found the problems identified by inspectors. Care plans and risk assessments were not consistently updated, including for wounds, weight loss and capacity.
“Quality assurance systems had failed to identify the areas of concern we highlighted during our inspection.” from the report
Mixed experiences of staff skills
needs fixingStaff did not always receive specialist training for the people they supported. Some people reported communication difficulties with some staff.
“Staff did not receive specialist training relevant to the people they were supporting; for example, training in diabetes or Parkinson's disease.” from the report
- 01How many registered nurses and care staff are now on duty on each shift, and how do you check this matches people's needs?
- 02What has changed to make sure medicines, wound care, supplements and weight loss are safely monitored and recorded?
- 03How do you make sure people choose when to get up, receive personal care and use the toilet where they can?
- 04How are mental capacity and best-interest decisions recorded, including decisions about restrictions and cultural or religious choices?
- 05What evidence can you show that your audits now identify and correct problems before they affect people?
This was an unannounced first comprehensive inspection covering all five key questions, prompted partly by concerns about end-of-life care, staffing and safety, and including infection prevention and control. This explanation was written from the published report of 25 April 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, January 2021
Inspected but not rated; inspectors found good Covid-19 infection control arrangements.
Inspectors visited the home on 30 November 2020. The visit was announced and focused on infection prevention and control because the home was being used as a designated setting for people leaving hospital with Covid-19.
The home had a separate unit for up to five people who had tested positive. Inspectors found arrangements for safe admissions, personal protective equipment, testing, cleaning, laundry, meals and visitors.
People in the unit could keep in touch with loved ones by telephone and video. Staff worked only in the unit, and staff could access confidential mental health support.
The home was inspected but not rated overall. The Safe question was also inspected but not rated. The other four questions were not assessed in this visit.
Staff kept separate
Staff working in the designated unit did not work elsewhere in the home or in other health or social care services. This reduced the risk of cross infection.
“Staff had been allocated to work solely within the designated unit.” from the report
Visitor precautions
Visiting professionals were given PPE and were screened before entering the designated unit.
“Personal Protective Equipment such as masks, gloves and aprons were available to visiting professionals on entry to the designated unit.” from the report
Contact with loved ones
People in the designated unit were supported to stay in touch with relatives by telephone and video. They also had disposable activity boxes while isolated.
“People staying within the designated setting were being supported to maintain contact with loved ones via video and telephone.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection prevention and control arrangements are in place now for people admitted after testing positive for Covid-19 or another infection?
- 02Are staff still allocated solely to any designated infection-control unit, and do they work in other parts of the home?
- 03How are visitors screened and provided with PPE, and what are the current visiting arrangements?
- 04How will a relative be helped to stay in contact with someone who is isolated?
- 05What are the home’s current ratings for Effective, Caring, Responsive and Well-led, since these were not assessed in this inspection?
This was an announced, focused inspection of infection prevention and control in the designated setting; the service was inspected but not rated and the other four key questions were not assessed. This explanation was written from the published report of 22 January 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.
Every inspection of Delves Court Care Home
2 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- April 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2021Inspected but not ratedSafe: Inspected but not rated
- February 2018GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2020
Registered with the Care Quality Commission on 15 May 2020.
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 Walsall
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 £1,200 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.”
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.