CQC report explained · a nursing home
What the CQC found at Duncote Hall Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were generally protected from harm and known risks had been assessed. However, some bathing water temperatures were too high, some checks were not recorded and prescribed fluid thickener was not always recorded as given.
- Effective?
- Requires improvement
- Staff were trained and worked with health professionals, and people's food and fluid needs were monitored. Pre-assessments were not in place and there was limited evidence of valid consent forms for some people.
- Caring?
- Good
- People were treated with kindness, dignity and respect. They were involved in care planning and their choices, privacy and independence were supported.
- Responsive?
- Requires improvement
- Care plans recorded people's needs, preferences and communication needs. However, activities were not offered every day, including at weekends, and some people experienced delays when asking for support.
- Well-led?
- Requires improvement
- Management systems and audits had improved, but they did not always identify gaps in records or care checks. The leadership and oversight arrangements still needed to be embedded and reviewed.
What inspectors found, August 2021
Rated Requires Improvement and no longer in special measures; inspectors found kind care, but some safety, response and management systems still needed strengthening.
This was an unannounced follow-up inspection on 7 July 2021. Two inspectors visited, spoke with people, relatives and staff, and checked care, medicines, staffing and management records. They also checked infection control arrangements during the COVID-19 pandemic.
The home had improved since its last inspection, when it was rated Inadequate and had several legal breaches. Inspectors found no breaches at this visit. However, some systems were not yet fully embedded. They found problems including incomplete medicine records, water temperatures above the recommended level, gaps in some checks and limited evidence of consent paperwork.
People and relatives described staff as kind, respectful and familiar with people's needs. The caring rating was Good. Safe, Effective, Responsive and Well-led were Requires Improvement. The home had improved enough to leave special measures, but CQC said it would continue to monitor the service.
Kind and respectful staff
Inspectors saw staff taking time with people and supporting them compassionately. People and relatives said staff knew them, respected their dignity and involved them in decisions.
“We saw staff interacting with people in a compassionate way and taking their time with each person.” from the report
Infection control
The home had arrangements for PPE, testing, visits, social distancing and managing possible outbreaks during the pandemic.
“We were assured that the provider was using PPE effectively and safely.” from the report
Safe recruitment and training
The home completed recruitment checks, including references and DBS checks. Staff received training, induction and shadow shifts before working alone.
“Records confirmed that Disclosure and Barring Service (DBS) checks were completed and references obtained from previous employers.” from the report
Links with health professionals
People were referred to appropriate professionals, and information from their involvement was recorded in care notes.
“Staff worked closely with healthcare professionals such as speech and language therapists, GP's and dieticians.” from the report
Progress since the last inspection
The home had made enough improvement to move from Inadequate and leave special measures. It was no longer in breach of the regulations identified at previous inspections.
“During this inspection the provider demonstrated that improvements have been made.” from the report
Bathing water temperatures
seriousRecords showed water temperatures reached 45°C on 11 occasions over three months. This created a risk of scalding, although monthly checks of the temperature controls were in place.
“Records of water temperatures taken when people were supported with bathing evidenced temperatures reached 45 degrees eleven times during a three-month period.” from the report
Incomplete medicine records
seriousStaff did not always record when prescribed fluid thickener had been given. A new signing sheet was introduced immediately after the inspection, and inspectors found no evidence of harm.
“We found when people had fluid thickener prescribed to reduce choking risks staff had not recorded when thickener was given.” from the report
Consent paperwork
needs fixingSome consent forms had been signed by relatives who did not have the legal authority to do so. The manager was replacing the forms and arranging best-interest meetings where needed.
“Previous consent forms had been signed by relatives who did not have the legal powers to do so.” from the report
Delays in responding
needs fixingTwo people said staff were sometimes slow to respond, including when people needed personal care or had been left on a commode.
“People told us staff were kind, however two people stated at times staff had not responded quickly to their needs.” from the report
Activities were not daily
minorPeople said there were no structured activities at weekends. Staff did not always have time to sit with people for activities.
“One person told us, there were no structured activities at weekends and staff did not always have time to sit with people to complete an activity.” from the report
Management checks missed gaps
needs fixingAudits and daily checks had improved, but they did not always identify missing records or patterns in incidents. The home was asked to embed and review these systems.
“Systems and processes to ensure people received safe care were in place but required embedding and reviewing.” from the report
- 01What changes have been made to record prescribed fluid thickener and other medicines, and how are these records now checked?
- 02How do you monitor bathing water temperatures, and what happens if a temperature is above the safe level?
- 03Have all consent forms been corrected, and are best-interest meetings completed for people who cannot make particular decisions?
- 04How often are structured activities now offered, including at weekends?
- 05How do you monitor response times when people need personal care or assistance?
This was an unannounced follow-up inspection covering all five key questions, with additional checks of infection prevention and control arrangements during the COVID-19 pandemic. This explanation was written from the published report of 12 August 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, September 2020
Rated Inadequate and still in special measures; inspectors found serious risks in care records, medicines, skin care and management oversight.
This was an unannounced focused inspection on 2 and 16 July 2020. Inspectors looked only at Safe and Well-led. They spoke with people and staff, and checked care records, medicines records, staff files, rotas, training and quality checks.
Inspectors found that people were at risk because medicines were not always given or recorded correctly. Pressure ulcer care, repositioning, safety checks and care plans were not consistently completed. Unexplained bruises and injuries were not always investigated or recorded properly.
The home had enough staff, followed safe recruitment procedures, and appeared clean and well maintained. People said they felt safe and that staff were kind. New systems had been introduced after the inspection, but inspectors could not yet be sure they were working consistently.
The overall rating remained Inadequate. Safe and Well-led were both rated Inadequate. The home remained in special measures because enough improvement had not been made or sustained.
Enough staff
Inspectors found enough care staff to meet people's needs safely and without rushing them. Recruitment checks were also completed.
“There were sufficient care staff available to meet people's needs safely and in a timely way.” from the report
Improved infection control
The home was meeting the infection control requirement that had been breached previously. Staff used protective equipment and the environment was clean.
“People were protected from the risks of infection as the staff supporting them had undergone training in infection prevention and undertook safe practices when providing care.” from the report
Kind staff
People told inspectors that staff were gentle and understanding, and that they felt safe.
“I feel safe, the staff are gentle and understanding. I can tell them if I don't like something.” from the report
Medicines were not consistently safe
seriousStaff did not always follow instructions for medicines given when needed. Records were incomplete, and some staff had not had their ability to give specific medicines checked regularly.
“On six occasions the dose given to the person was the full prescribed amount and on five occasions staff had not completed ABC charts.” from the report
Pressure ulcer risks
seriousSome specialist mattresses were set incorrectly. Repositioning was missed, and some pressure sores did not have wound care plans.
“We found 15 different occasions when people had been left for longer than their prescribed amount of time.” from the report
Injuries were not properly investigated
seriousUnexplained bruises and other injuries were not always investigated. Body maps did not always record enough detail to support correct treatment.
“The provider had not investigated the reasons for people's unexplained bruises.” from the report
Care records were incomplete
seriousCare plans and daily records did not always contain the information staff needed. Some safety, repositioning and bowel monitoring records were missing or inconsistent.
“Staff did not have all the information they required to provide safe care.” from the report
Weak management checks
seriousAudits failed to identify important problems, and some actions were left outstanding. This meant the provider did not reliably know when care standards had fallen short.
“The provider failed to have adequate systems in place to monitor the quality care being provided.” from the report
- 01How are you now checking that medicines given when needed follow the correct dose and recording instructions?
- 02How do you check that people are repositioned on time and that specialist mattresses are set correctly?
- 03How are unexplained bruises, pressure sores and other injuries investigated, treated and reviewed?
- 04How do you make sure care plans contain all the information staff need, including bowel monitoring and safety checks?
- 05What evidence can you show that the new quality checks and action plans are now working consistently?
This was a focused inspection of Safe and Well-led only; the other key questions were not inspected and previous ratings were used in calculating the overall rating. This explanation was written from the published report of 4 September 2020 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 Duncote Hall Nursing Home
7 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- August 2021Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2020Inadequatestayed InadequateSafe: InadequateWell-led: Inadequate
- May 2020Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2019Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- February 2019Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 7 December 2010.
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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