CQC report explained · a nursing home
What the CQC found at Dormy House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2024
Rated Inadequate and placed in special measures; inspectors found serious safety, staffing, care and leadership failures.
This was an unannounced inspection on 23 October and 2 November 2023. Four inspectors spoke with people, relatives, staff and outside professionals. They reviewed care records, medicines records, incidents, complaints, recruitment files and quality checks.
Inspectors found unsafe management of choking, falls, fluids, medicines and accidents. There were not enough staff at times, and some staff lacked effective training and supervision. People were not always protected from alleged abuse or neglect.
Care was not always dignified or personalised. Care plans lacked important information, activities were limited, complaints were not always investigated, and mealtimes could be chaotic. Inspectors also found that leaders' checks did not identify or fix important problems.
The overall rating was Inadequate. Safe and well-led were rated Inadequate, while effective, caring and responsive were rated Requires Improvement. This is worse than the previous overall rating of Good, published on 13 May 2021.
Safe recruitment
The home used references and Disclosure and Barring Service checks when recruiting staff.
“The provider operated effective and safe recruitment practices when employing new staff.” from the report
Health care access
People could access health care, and the home worked with several health professionals. Assessments were completed before people moved in.
“We saw evidence of visits from various health care professional including opticians, community nurses, hospice nurse, physios and occupational therapists.” from the report
Some caring staff
Although care was inconsistent, inspectors saw staff greeting people warmly and protecting privacy during personal care.
“When personal care was being delivered staff always ensured the bedroom or bathroom door was closed to protect the person's dignity.” from the report
Some clinical care
Inspectors saw staff supporting repositioning, checking blood sugar levels and using hoists safely in the examples reviewed.
“We observed where people required to hoisted, staff were undertaking this in a safe way to reduce risk of harm to the person.” from the report
Unsafe care risks
seriousChoking, falls, fluid restrictions and accidents were not managed consistently. Records did not always explain what had happened or what would prevent further harm.
“The failure to ensure risks to people's safety were robustly assessed was breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Medicines problems
seriousSome medicines lacked clear instructions, stock counts were inaccurate, records had gaps and equipment was dirty. This created a risk that people could receive the wrong medicine or miss doses.
“The failure to ensure medicines were managed in a safe way was a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Staffing and supervision
seriousPeople were sometimes left without the support they needed, including during meals and when at risk of falling. Many staff had not received suitable supervision.
“The failure to ensure there were appropriate levels of staff deployed at the service was a breach of regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014” from the report
Safeguarding
seriousAllegations of people being hit were not always recognised, investigated or reported to safeguarding teams. Injuries were not always investigated to reduce further risks.
“The failure to ensure people were protected from the risk of abuse was a breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Dignity and daily life
seriousPeople were not always supported with personal care, appearance, choices or meaningful activities. The broken lift also left some people isolated in their bedrooms.
“The provider had failed to ensure people were always treated with dignity and respect and were always given choices around their delivery of care this was a breach of regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Weak oversight
seriousAudits and other checks failed to identify serious issues with medicines, choking risks, staffing and care quality. Complaints and feedback did not consistently lead to action.
“The failure to ensure quality assurance and governance systems were effective was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014.” from the report
- 01How many permanent and agency staff are now working on each shift, especially at mealtimes?
- 02What checks now make sure choking risks, modified meals, fluid restrictions and falls plans are followed?
- 03How are medicines now checked, including as-and-when medicines, stock counts and missing MAR entries?
- 04How are safeguarding allegations, injuries, accidents and complaints recorded, investigated and followed up?
- 05What activities, care-plan changes and communal arrangements are now in place for people affected by the broken lift or living with dementia?
This was an unannounced inspection that looked at the care provided and the premises, examined concerns about safe care, staffing and choking risks, and rated all five key questions. This explanation was written from the published report of 30 January 2024 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 2023
Inspected but not rated; inspectors found generally safe, kind support, but identified gaps in risk records and health monitoring.
This was an unannounced targeted inspection on 9 November and 1 December 2022. Inspectors looked at concerns about falls, mobility, nutrition and hydration, rather than carrying out a full inspection.
Inspectors spoke with people, relatives, staff and a GP. They observed care, reviewed care files and health records, and examined audits, policies and procedures. They found that risks were usually assessed, recorded and reviewed, and that people were supported with food, drink and healthcare.
There were some gaps. Repositioning records were not always completed, some behaviour incidents were not escalated properly, one assessment did not record the outcome of a required area, and the home was not using national tools for early signs of health deterioration.
The overall service and the Safe and Effective questions were inspected but not rated. The previous rating was Good, published in May 2021, but this visit did not review all areas needed to change the ratings.
Risk assessments
Inspectors found that risks were usually identified, recorded, shared with staff and reviewed. Equipment and extra checks were used for people at higher risk of falls.
“Risks to people were identified and actions to reduce risk were documented, shared with staff supporting people and reviewed regularly.” from the report
Food and drink support
People had choices and were encouraged to eat and drink. Staff adapted meals and provided fortified food where people were at risk of malnutrition.
“People had access to plenty of food and drink choices throughout the day and we observed staff were attentive and encouraged intake.” from the report
Healthcare support
Records showed referrals and appointments with several healthcare professionals. A GP said staff understood people's changing health needs and made suitable referrals.
“Records showed the service supported people to access a range of healthcare services.” from the report
Involvement in decisions
Care reviews involved people and their relatives. Consent, capacity assessments and best-interest decisions were recorded for care and treatment.
“Care review records showed people and their relatives were involved in decisions about their care.” from the report
Kind and sensitive care
Inspectors saw staff anticipating people's needs and supporting them with sensitivity. People appeared relaxed and responded positively to staff.
“We observed staff anticipated people's needs and supported people with sensitivity and kindness.” from the report
Repositioning records
needs fixingNight staff had not consistently recorded repositioning in line with one person's care plan. Inspectors found no harm, and records had improved by the second inspection day.
“During day one we found night staff had not consistently recorded repositioning in accordance with a person's care plan.” from the report
Incomplete assessment recording
needs fixingStaff did not record the outcome of the expressing sexuality part of people's initial assessments. The manager said this would be addressed through reminders and audits.
“We found staff did not record the outcome of 'expressing sexuality' as part of people's initial assessment.” from the report
Health deterioration monitoring
needs fixingThe home was not using nationally recognised early-warning tools for signs of health deterioration. It did have other systems for checking vital signs and reporting concerns.
“The service did not follow national tools available for early warning signs of health deterioration, however, systems were in place to check and record people's vital signs” from the report
- 01How do you now check that repositioning is recorded consistently for people who need it?
- 02What happens when an ABC behaviour incident shows a risk to the person or to others?
- 03How do you make sure the expressing sexuality assessment is completed or recorded when someone does not wish to discuss it?
- 04What system do you use to spot and respond to early signs of health deterioration, given that national early-warning tools were not being used?
- 05What is the current outcome of the CQC investigation into the incidents that prompted this inspection?
This was a targeted inspection of specific risks relating to mobility, falls, nutrition and hydration; it did not fully assess all five key questions, so the previous ratings were not changed. This explanation was written from the published report of 13 January 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 Dormy House
6 rated inspections over 9 years: the service has slipped, from Good to Inadequate.
- January 2024Inadequatecurrent ratingSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2023Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not rated
- May 2021Goodstayed GoodSafe: GoodWell-led: Good
- January 2020Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2017Goodstayed GoodSafe: Requires improvement
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- April 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- July 2013
Registered with the Care Quality Commission on 4 July 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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