CQC report explained · a nursing home
What the CQC found at Emsworth House Care Home with Nursing
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2023
Rated Requires Improvement for the third consecutive inspection; inspectors found serious shortfalls in staffing, risk management, medicines and oversight.
The inspection was unannounced and took place over three days. Inspectors spoke with people, relatives, staff and health professionals. They observed care and reviewed care, medicines, staffing and management records.
The home did not always have enough suitably skilled staff. Inspectors found problems with falls risks, fluid monitoring, bed rails, food textures, medicines records and the safe storage of items. Around 30% of staff had not completed training considered mandatory.
There were also weaknesses in the home's checks and records. Audits had not identified the problems found, and some concerns from earlier inspections had not been fully resolved. People were generally protected from abuse, the home was clean overall, and inspectors saw kind care from permanent staff.
The overall rating was Requires Improvement. Safe, Effective and Well-led were also rated Requires Improvement. Caring and Responsive were not rated in this report.
Safeguarding
The home had safeguarding procedures and staff understood their responsibilities. Most people and relatives said they felt safe.
“The provider had effective safeguarding procedures in place and people were protected from the risk of abuse.” from the report
Kind permanent staff
People and relatives spoke positively about the caring nature of permanent staff. Inspectors also saw kind interactions.
“People and their relatives provided positive feedback about the caring nature of the permanent staff, and we saw kind and caring interactions.” from the report
Health professional links
The home worked with health and social care professionals, including GPs, district nurses and speech and language therapists.
“The provider worked in partnership with health and social care professionals to maintain people's health.” from the report
Safe recruitment and infection control
Recruitment checks were described as safe. The home was clean overall and inspectors were assured about most infection prevention arrangements.
“Staff were recruited safely. The registered manager told us they used a 'values-based' recruitment system to ensure staff who were employed had the right values.” from the report
Not enough staff
seriousStaff were not always available to meet people's needs. Inspectors saw people waiting for help and found that sensor alarms were not always answered promptly.
“The provider failed to deploy enough suitably skilled and competent staff to meet people's needs.” from the report
Risks not consistently managed
seriousInspectors found gaps in falls and dehydration assessments, unsafe bed rail arrangements, incorrect food textures and unsafe access to some items. These issues increased the risk of harm.
“The provider failed to always ensure risks to people were well managed and reduced.” from the report
Medicines problems
seriousMedicine records were incomplete in several ways. Creams were not always stored securely, some opening dates were missing, and time-specific medicines were not always recorded at the correct time.
“The management of medicines was not always safe.” from the report
Training gaps
seriousAround 30% of staff had not completed mandatory training. Many care staff had also not completed training for needs such as swallowing difficulties, diabetes and dementia.
“Approximately 30 percent of staff had not completed training the provider considered mandatory for staff to carry out their roles effectively.” from the report
Weak quality checks
needs fixingThe home's audits had not identified the problems found during inspection. Earlier concerns, including food consistency and mental capacity records, had not been fully embedded into practice.
“Quality assurance systems had not been effective in identifying the concerns we found at inspection or driving the necessary improvement.” from the report
- 01How many permanent and agency staff are currently working on each shift, and how do you make sure there are enough staff throughout the day?
- 02What has changed to make sure staff respond promptly to falls alarms and provide the support people need?
- 03How are medicines now checked, stored and recorded, including creams, opening dates, time-specific medicines and as-required medicines?
- 04How do you check that staff have completed and understood training for dementia, diabetes and swallowing difficulties?
- 05What action has been taken to improve mental capacity and consent records, and how will you show that the changes are being maintained?
The report gives ratings for Safe, Effective and Well-led only; Caring and Responsive were not rated in this inspection report. This explanation was written from the published report of 20 April 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, September 2019
Rated Requires Improvement; inspectors found safe, kind and responsive care, but weaknesses remained in consent records and quality checks.
This was a planned inspection on 18 and 19 July 2019. Inspectors spoke with people, relatives and staff, reviewed care records and other documents, observed care, and gathered further information after the visit.
People generally said they felt safe and happy. Inspectors found good standards in safety, caring and responsiveness. The home was clean, staff were trained, people received help with food, drinks and healthcare, and activities were available.
The overall rating remained Requires Improvement, as it had been at the previous inspection. The main problems were inconsistent records about mental capacity and best-interest decisions, and quality systems that had not always identified or fixed problems promptly.
People felt safe
People said they felt safe, and staff understood how to recognise and report abuse. Risks such as falls, pressure injuries, choking and mobility were assessed and managed.
“People said they felt safe at the home. For example, one person told us, "I am 100% safe here. I would give the staff 10/10 for keeping you safe.” from the report
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff protect privacy, offer choices and support people to do what they could for themselves.
“People and family members spoke positively about staff, describing them as "kind" and "caring".” from the report
Personalised support and activities
Care plans reflected people's needs and preferences. The home offered activities, trips and individual 'wishes' to help people take part in things that mattered to them.
“People had access to a range of activities. These included: exercise sessions, quizzes, singing, bingo and craft work.” from the report
End-of-life care
Inspectors found staff had strong experience in supporting people at the end of life. People's preferences were discussed with them and their families and recorded.
“At the end of their lives, people received appropriate care to have a comfortable, dignified and pain free death.” from the report
Mental capacity records
needs fixingStaff did not consistently record capacity assessments and best-interest decisions in the correct order or with the views of people consulted. This affected records about care, movement monitoring and hidden medicines.
“Where an MCA assessment had been completed and had concluded that the person lacked capacity, a best interests decision was not always recorded, together with the views of the people consulted.” from the report
Quality checks did not always work
needs fixingThe provider's checks had not identified or dealt with some problems promptly. This included the mental capacity records, stopped updates to evacuation information and out-of-date fire safety training.
“However, the systems had not always been effective in identifying and addressing concerns.” from the report
Some safety procedures needed improvement
needs fixingInspectors found gaps in fire safety training, the evacuation summary kept in the reception grab bag, catheter monitoring in the residential unit and checks for some medicines. The manager took action during or after the inspection.
“In the residential unit, although staff monitored people's catheters, this was not done as consistently.” from the report
Mixed views about staffing and meals
minorSome people and staff said there were times when staff were under pressure or people waited for help. Views about food were also mixed, including comments about chewy meat and vegetables not being cooked enough.
“Two people told us they sometimes had to wait to be supported to use the toilet which could make them "upset".” from the report
- 01How are you now recording mental capacity assessments and best-interest decisions, and can you show how the person's views and the views of those consulted are included?
- 02How do you check that decisions about hidden medicines and movement-monitoring equipment have the correct legal records?
- 03How do you make sure all staff have up-to-date fire safety training and that the evacuation information in the grab bag matches people's current needs?
- 04How are catheter monitoring and medicine checks in the residential unit being audited now?
- 05What changes have been made to staffing arrangements to prevent people waiting for help when staff are under pressure?
This was a planned inspection covering all five key questions, and it included both the accommodation and the care provided. This explanation was written from the published report of 4 September 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 Emsworth House Care Home with Nursing
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- April 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Emsworth House Care Home with Nursing →
- September 2019Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementWell-led: Requires improvement
Read what inspectors found at Emsworth House Care Home with Nursing →
- July 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 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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