CQC report explained · a residential care home
What the CQC found at Dudley Court Care Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe medicine storage and administration, regular risk reviews and suitable safeguarding processes. They found no evidence that people were harmed by the concerns that prompted the inspection.
- Effective?
- Good
- People's needs were assessed and care plans updated. Staff had suitable training, and people were supported with food, drinks, specialist diets and access to healthcare.
- Caring?
- Good
- People and relatives described staff as kind, caring and respectful. People were involved in daily decisions and supported to maintain privacy, dignity and independence.
- Responsive?
- Good
- Care plans reflected people's preferences and were reviewed when needs changed. People were offered activities, welcomed visitors and had ways to raise concerns.
- Well-led?
- Good
- Inspectors found improved audits and management oversight. People, relatives and staff reported significant improvements since the previous inspection and said managers were approachable.
What inspectors found, August 2023
Rated Good; inspectors found safe, kind and responsive care, with improvements since the previous inspection.
The inspection took place over 13 and 14 July 2023. One inspector visited the home, spoke with people, relatives and staff, and reviewed care plans, medicine records, staff files and quality checks. The first day was unannounced and the second day was announced.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines practices, clean surroundings, suitable training and good support with food, drinks and healthcare.
People and relatives said staff were kind and involved them in care decisions. Care was personalised, activities were available and complaints systems were in place. The home had improved from Requires Improvement at the previous inspection and was no longer in breach of regulations.
Safe medicines
Medicines were stored and given safely. Staff had training and competency checks, including for medicines with specific timing instructions.
“Medicines records were maintained, and medicines were stored and administered safely.” from the report
Kind and respectful staff
People said staff were kind and respectful. Inspectors also observed staff speaking with people in a respectful way.
“People told us staff were kind, caring and respectful and our observations confirmed this.” from the report
Personalised care
Care plans included people's preferences, such as their preferred drinks, personal care routines and whether they preferred male or female carers.
“Care plans were personalised to reflect people's preferences.” from the report
Improved management
The home had introduced audits and made changes to the environment and equipment checks. Staff, people and relatives reported significant improvements since the last inspection.
“There had been an improvement with the provider's governance processes.” from the report
Activities and family contact
Visitors were welcomed and people were encouraged to join activities, including entertainers, gentle exercise and trips such as pub lunches.
“People were encouraged and invited to participate in a wide variety of activities that may be of interest to them.” from the report
Building looked tired
minorOne relative described the outside of the building as looking a little tired. The report says further changes were planned to make the environment more dementia friendly.
“It's an old house and looks a little tired from the outside but it has a lovely, homely feel to it” from the report
- 01What dementia-friendly changes have been made since the inspection, and what further changes are planned?
- 02How will you make sure my relative receives medicines at the prescribed times and that records remain complete?
- 03How often will my relative's care plan and risk assessments be reviewed if their needs change?
- 04What activities would be suitable for my relative's interests, abilities and communication needs?
- 05How will you involve me in care reviews and decisions about my relative's support?
This inspection examined the risks that prompted it, including medicines, staffing, training and pre-assessment, and rated all five key questions; the previous comprehensive inspection was published in 2021. This explanation was written from the published report of 25 August 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, June 2021
Dudley Court Care Limited is rated Requires Improvement; inspectors found concerns about medicines records and management oversight, although safeguarding, staffing and infection control had improved.
This was an unannounced inspection on 21 and 26 April 2021. One inspector spoke with people living in the home, relatives, staff and health professionals. They reviewed care records, medicines records, staff files and management records.
The home was rated Requires Improvement overall, with Safe and Well-led also rated Requires Improvement. Inspectors found that medicines prescribed for use when needed were sometimes given daily or without a recorded reason. Management audits did not always identify gaps or inconsistencies in care, handover, medicines, complaints and safeguarding records.
There were also improvements. Risks such as falls and choking were assessed, people said there were enough staff, medicines were stored safely, and infection control was in line with current guidance. Safeguarding systems had improved and were no longer in breach.
The overall rating stayed at Requires Improvement, the same as at the previous inspection published in April 2020. The provider remained in breach of Regulations 12 and 17, and the CQC issued a warning notice for governance.
Safeguarding improved
Safeguarding concerns were considered and shared with other professional bodies when required. Staff knew how to report concerns.
“At this inspection, we found all safeguarding risks had been considered and concerns had been escalated and shared with other professional bodies as required.” from the report
Risk assessments
Inspectors found that risks such as falls, choking and oral health had been assessed, with measures in place to reduce those risks.
“We saw assessments for the risk of falling, choking and oral health, which included pro-active measures to manage the risk.” from the report
Staffing and infection control
People said there were enough staff to meet their needs. Inspectors were assured that infection control arrangements followed current guidance.
“People told us there was a sufficient number of staff to meet their needs and keep them safe.” from the report
Family involvement
The home kept in regular contact with families and held monthly meetings with residents about issues including privacy, menus and cleanliness.
“Resident meetings were held monthly and discussed topics such as privacy, menus and cleanliness of the home.” from the report
Medicines given when needed
seriousMedicines prescribed for agitation were sometimes given daily, including when records did not show that the person was agitated. The records did not always explain why the medicine was given.
“We found PRN medicines for agitation were being administered daily.” from the report
Weak management audits
seriousThe audit system did not reliably find problems in care records, handover records or medicines records. This limited the manager's oversight of safety and quality.
“Audit systems had been implemented however these were not sufficiently robust to identify areas of concern and develop action plans.” from the report
Incomplete records
needs fixingSome complaints and safeguarding concerns had not been entered into the relevant logs. One medicine protocol had not been reviewed since December 2019.
“The registered manager informed us of complaints that had been made by people receiving the service and the actions taken to resolve these. However, neither the complaints nor their outcomes had been recorded in complaints log.” from the report
- 01What checks now make sure medicines prescribed for use when needed are given only when needed and have a recorded reason?
- 02How often are medicine protocols reviewed, and what happens if an audit finds a missing rationale or inconsistent record?
- 03How do you check that daily care records and handover records match?
- 04How are complaints and safeguarding concerns recorded, reviewed and followed up?
- 05What action has been taken in response to the Regulation 17 warning notice?
This was a focused inspection of Safe and Well-led, including infection control and concerns about medicines, staffing and continence care; the other key questions were not inspected and their previous ratings carried over. This explanation was written from the published report of 29 June 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 Dudley Court Care Limited
7 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- August 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2021Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- April 2020Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2019Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 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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