CQC report explained · a residential care home
What the CQC found at Dorrington House (Wells)
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2021
Rated Requires Improvement; inspectors found risks in staffing, premises, infection control and management oversight.
This was an unannounced, focused inspection on 26 November 2020. Inspectors spent one day at the home and reviewed safety, infection control, care plans, medicines, staffing, recruitment, equipment and management records. They also spoke with staff, relatives and healthcare professionals.
The home was not always safe. Inspectors found unsafe or poorly maintained equipment, risks in bathrooms and other areas, incomplete risk assessments, staffing gaps and training gaps. Cleaning was not consistently good, and people were not fully protected from infection risks. Medicines were generally managed safely, but inspectors found some problems with administration and follow-up.
The home was also not well-led. Its checks had not found or fixed important problems, and earlier improvements had not been sustained. The overall rating stayed at Requires Improvement, as did Safe and Well-led. The other key questions were not inspected during this visit, so their previous ratings were used in the overall rating.
Medicines staff
Staff administering medicines had been trained and assessed as competent. Inspectors found that medicines were generally managed safely, despite some concerns.
“People were administered medicines by staff who were sufficiently trained and assessed as competent to give medicines.” from the report
Protective equipment
Staff were observed wearing the correct protective equipment safely throughout the shift.
“Staff were wearing the personal protective equipment effectively and safely.” from the report
Family communication
Most relatives received regular updates, and relatives generally felt communication with the home was good.
“Most relatives had not had face to face contact with their family member for some time but received regular updates.” from the report
Healthcare links
Healthcare professionals gave positive feedback and said the home made appropriate referrals when people's needs changed.
“We received positive feedback from health care professionals who worked closely with the service and who felt the service made timely and appropriate referrals.” from the report
Unmanaged safety risks
seriousInspectors found unsecured creams and cleaning products, unsafe or poorly maintained equipment, and other hazards in the building. These risks had not been properly identified by the provider.
“We found creams and cleaning products which were not locked away and if ingested could cause harm.” from the report
Staffing and training gaps
seriousStaffing levels were not always enough to cover the assessed needs of people. Some staff working unsupervised did not have up-to-date manual handling training.
“Training records showed that several staff currently showing on the rota and working unsupervised did not have current training in manual handling.” from the report
Infection control
seriousSome areas were not clean enough, cleaning schedules were not consistently completed, and risks linked to social distancing and people entering other rooms had not been fully considered.
“We were not assured that the provider was promoting safety and maintaining effective hygiene practices across the premises.” from the report
Recruitment checks
seriousRecruitment records did not always show that staff were suitable or had the necessary skills. Some interviews and risk assessments were not detailed enough.
“The provider had not ensured there was a robust recruitment process in place which protected people as fully as possible.” from the report
Weak quality checks
seriousThe home's audits and monitoring systems had not identified several problems found by inspectors, including equipment servicing, night care and accident trends.
“The quality assurance processes were ineffective at identifying areas for improvement and had not identified the concerns found during the inspection.” from the report
Limited engagement
needs fixingInspectors saw limited interaction and meaningful activity. One person called for help but was told to wait without staff first checking what they needed.
“The care we observed on the day of inspection was not sufficiently person centred.” from the report
- 01What has been done to make sure all staff working with residents have current manual handling and infection control training?
- 02How have you fixed the problems with slings, hoists, fire equipment, electrical checks and other maintenance records?
- 03How are you now checking that creams and cleaning products are secured and that bathrooms and other areas are safe?
- 04What changes have been made to cleaning routines and to reduce infection risks, especially at night?
- 05How do your current audits identify concerns about staffing, accidents, medicines, activities and residents' day-to-day experience?
This was a focused inspection of Safe and Well-led only; the other key question ratings carried over from previous comprehensive inspections. This explanation was written from the published report of 27 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.
What inspectors found, October 2019
Rated Requires Improvement; inspectors found kind and responsive care, but safety, staffing, cleanliness and management needed significant improvement.
This was an unannounced inspection on 20 August 2019. Inspectors spoke with people, relatives, staff and a visiting professional. They observed care, meals and medicines, and checked care plans, medicines records, staff files and management records.
The home was caring and responsive. Staff knew people well, care plans were detailed, and there were activities to support wellbeing. People received healthcare support and relatives generally said they were happy with the care.
However, people were sometimes left unsupervised and staff could not always respond promptly. Inspectors found hazards, poor cleanliness, unsafe or unsuitable moving and handling slings, weak recruitment records and gaps in management checks. The home had improved its medicines arrangements, but the overall rating fell from Good to Requires Improvement.
Kind and respectful staff
Staff were familiar with people's needs and generally treated people respectfully. Relatives were mostly happy with the care and communication.
“Generally, we found staff respectful of people's needs and we saw some good interactions.” from the report
Personalised care
Care plans were detailed and based on assessments of people's needs and preferences. Families were consulted and kept informed about care and incidents.
“People had detailed care plans which were developed following an assessment of need.” from the report
Activities and relationships
The home offered group and one-to-one activities linked to people's interests, including singing, exercise, art and reminiscence. Links with families and the local community supported people's experiences.
“A range of activities were provided and helped to improve people's mobility, cognition and overall well- being, such as singing, pamper sessions, exercise classes and art sessions.” from the report
Improved medicines practice
Inspectors found that medicines arrangements had improved following errors and external checks. Staff giving medicines were trained and medicines were kept secure.
“We found medicine practices had improved. The service had recently had external audits from both the supplying pharmacist and the Clinical Commissioning group.” from the report
People left without supervision
seriousPeople were left in communal areas without a way to summon help. Inspectors also saw food and drinks left unattended, including items that could increase choking risks.
“People sitting in communal lounges and left unsupervised across the day including lunch time.” from the report
Unsafe and poor environment
seriousInspectors found a propped-open fire door, a damaged walking frame, debris and a cable that could be used for self-harm. The home was not cleaned to a suitable standard, and some slings were stained, worn and unlabelled.
“The service was not cleaned effectively.” from the report
Staffing pressures
seriousVacancies and ineffective deployment meant people did not always receive timely care. Some people remained in bed near lunchtime and people were often unoccupied while staff provided personal care.
“Staffing levels were not always appropriate to the needs of the people using the service and did not help ensure people received safe and timely care.” from the report
Recruitment checks
seriousOne recruitment file lacked employment and education history. Records also did not clearly show how risks linked to historical offences had been assessed.
“Recruitment processes were not sufficiently robust and did not ensure people were protected from potential risks.” from the report
Weak management checks
needs fixingAudits had not identified several immediate safety and cleanliness problems. Managers had also not shown that lessons from incidents were always learned.
“Management oversight was ineffective because it did not ensure the safety and well- being of people.” from the report
Consent and training records
needs fixingSome records did not clearly show consent or best-interest decisions. Inspectors also recommended stronger induction and supervision, and training in end of life care.
“Some records did not always reflect the decisions made or ensure consent had been sought.” from the report
- 01How many staff are now working on each shift, and how do you make sure people receive timely personal care?
- 02How do you prevent people being left unsupervised at lunchtime or without a way to summon help?
- 03What changes have been made to cleaning, moving and handling slings, mobility aids and other safety hazards?
- 04How do you check that recruitment files are complete and that any employment risks have been assessed?
- 05What practical end of life training, induction and direct supervision do staff now receive?
This was a planned but unannounced comprehensive inspection covering all five key questions, with the previous Good ratings reassessed. This explanation was written from the published report of 17 October 2019 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 Dorrington House (Wells)
3 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- January 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 4 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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13 live-in carers within about an hour of Norfolk
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 £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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.