CQC report explained · a residential care home
What the CQC found at Dorley House Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found safe recruitment, safeguarding procedures, suitable staffing and safe medicines systems. They noted that the electronic care system did not always make the order of care clear because several entries could have the same time stamp.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Management used audits, an improvement plan, staff meetings and feedback to monitor and improve the home. Inspectors found managers were open with relatives and worked with other health professionals.
What inspectors found, June 2023
Dorley House Residential Care Home was rated Good; inspectors found safe, caring support and strong management, with some records and improvements still being worked on.
This was an unannounced inspection on 15 May 2023. One inspector spoke with eight people, two relatives, a visiting health professional and five staff. They also observed care, checked records and reviewed information from the local authority and the home.
The home was rated Good overall. Safe and well-led were both rated Good. Inspectors found people were protected from abuse, medicines were given safely, the home was clean, and staff were recruited and supported properly.
The inspection followed safeguarding concerns about care and the environment. Inspectors found no evidence that people were at risk of harm from this concern. Some electronic care records did not clearly show the order in which care was provided, and redecoration was still in progress.
Safe medicines
Medicines systems had recently been reviewed with support from a specialist team. Staff had protocols for medicines given when needed, and their competence was checked.
“People received their medicines safely and in accordance with their prescription.” from the report
Clean environment
Inspectors found the home clean and tidy. Relatives also described bedrooms and bathrooms as clean and hygienic.
“The home is clean and tidy, their bedroom is basic but functional and is clean and hygienic as is their ensuite bathroom.” from the report
Kind staff support
People and relatives spoke positively about staff. Inspectors saw people responding openly and positively when staff spoke with them, with activities taking place during the day.
“The staff are very kind and patient. They relate well to my relative and she is happy in their company” from the report
Management oversight
The home had regular audits and an improvement plan covering day-to-day services and the environment. Staff meetings and individual supervision were also taking place.
“There was a programme of regular audits to monitor all aspects of the day to day running of the home” from the report
Care record timestamps
minorSeveral electronic entries had the same time stamp, so it was not always clear in what order care had been provided. The manager was encouraging staff to add handwritten notes.
“Although this did not impact on people's safety, it was not clear what order care needs had been provided.” from the report
Redecoration ongoing
minorSome communal areas had been redecorated, but further improvements to the environment were still planned.
“We saw that redecoration had taken place in communal areas, with further improvements planned.” from the report
- 01How are you making sure care records clearly show the order and timing of care provided?
- 02What remaining redecoration or environmental improvements are planned, and when will they be finished?
- 03What changes were made to medicines after the recent review, including medicines given when needed?
- 04How will you keep relatives updated through newsletters, calls and the home’s Facebook page?
- 05How do you identify and act on any new safeguarding concerns or changes in people's risk?
This was an unannounced inspection prompted by safeguarding concerns and focused on Safe and well-led; the report does not give new ratings for Effective, Caring or Responsive. This explanation was written from the published report of 1 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.
What inspectors found, May 2022
Rated Good; inspectors found people were safe and treated kindly, while records and some management checks were still being improved.
This was an unannounced, focused inspection on 10 May 2022. It followed concerns about safeguarding. Inspectors found no evidence that people were at risk of harm from this concern.
Inspectors looked mainly at Safe and Well-led. They spoke with people, visitors and staff, observed care, and reviewed care, medicines, recruitment, safeguarding and management records. They found staff knew people's needs, medicines were given safely, and infection control arrangements were in place.
The home was rated Good for Safe and Well-led. The overall Good rating also used ratings from the previous inspection for Effective, Caring and Responsive, which were not inspected this time. A new manager was reviewing the service, but was not yet registered with CQC.
Kind and respectful care
People responded positively to staff, and relatives spoke positively about the care. Inspectors observed kind and respectful support.
“I know they are safe here and being well looked after, staff are all lovely they are all very kind.” from the report
Safe medicines
Medicine systems and guidance were in place. Staff were trained and their practice was checked.
“Medicine systems were in place to ensure people received their medicines safely and in accordance with their prescription.” from the report
Staff support and training
There was ongoing training, induction and supervision. Staff said they felt supported to meet people's individual needs.
“Staff were supported in their roles and felt they had access to the training and support they needed to meet people's individual needs.” from the report
Safety checks
The home had regular checks covering areas such as fire safety, water temperatures and equipment. Fire drills had led to learning and improvements.
“A robust system was in place for environment and service checks.” from the report
Open management
Staff and relatives described the manager as approachable. The provider and manager used action plans and audits to support improvement.
“Staff told us they felt the new manager was approachable and that everyone was working together as a team to make positive improvements.” from the report
Records still being improved
needs fixingInspectors identified a need for more detail in daily records and other documentation. Work was under way to improve this.
“Improvements to the detail in daily records and documentation had been identified and staff were being supported to implement these improvements.” from the report
Some checks were not recorded
needs fixingThe manager carried out staff competency observations, but these were not documented. The home could show that related discussions had taken place.
“Although these observations were not documented, we were able to evidence that discussions had taken place during staff huddle meetings based on things the manager had identified during reviews and observations.” from the report
Manager registration in progress
minorThere was no registered manager in post at the inspection. A new manager had been recruited and was applying to register with CQC.
“At the time of our inspection there was not a registered manager in post.” from the report
Recruitment records
minorThe manager was reminded to record interview discussions about gaps in employment history clearly in future.
“We discussed with the manager the importance of recording discussions which took place during interview in relation to gaps in people's employment history.” from the report
- 01Has the new manager now completed registration with CQC?
- 02What changes have been made to improve the detail and completeness of daily care records?
- 03How are handwritten medicine entries now checked and countersigned?
- 04How are staff competency observations recorded and followed up?
- 05What has been done to improve communication with relatives?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous inspection. This explanation was written from the published report of 27 May 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 Dorley House Residential Care Home
7 rated inspections over 7 years: the service has held its Good rating throughout.
- June 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Dorley House Residential Care Home →
- May 2022Goodstayed GoodSafe: GoodWell-led: Good
Read what inspectors found at Dorley House Residential Care Home →
- June 2021GoodSafe: GoodWell-led: Good
- March 2021Inspected but not ratedSafe: Inspected but not rated
- January 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2019Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 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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Most charge £1,000 to £1,400 a week. 13 can care for a couple. 10 years' experience on average.
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