CQC report explained · a nursing home
What the CQC found at Falkland Grange Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Staffing, recruitment, medicines, risk assessments and infection control were found to be safe, although falls investigations and some risk records needed clearer detail.
- Effective?
- Good
- People's physical, emotional and social needs were assessed and met. Staff were trained, nutrition and hydration were managed well, and the home worked effectively with health professionals.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- Managers promoted an open, person-centred culture and had strong systems for checking quality, safety and people's experiences. Staff, relatives and health professionals described the home as well managed.
What inspectors found, September 2022
Rated Good; inspectors found safe, kind and well-organised care, but falls investigations and some records needed improvement.
This was an unannounced focused inspection on 30 and 31 August 2022. Inspectors reviewed the safe, effective and well-led areas because concerns had been raised about staffing, falls, unsafe care, reporting and the staff culture. They spoke with people, relatives, staff and health professionals, observed care and medicines rounds, and checked records.
The inspectors found people were safe. There were enough suitably trained staff, medicines were managed safely, recruitment checks were robust and infection control arrangements were effective. Care was based on people's needs and choices, staff worked well with health professionals, and people were supported with food, drink, activities and communication.
The home had an open and caring culture. Managers monitored quality and acted on concerns. However, records did not always explain fully what had caused falls or how the risk of further falls had been reduced. Inspectors recommended extra training for managers in investigating accidents and incidents.
The overall rating was Good, and the safe, effective and well-led ratings were Good. Caring and responsive were not inspected during this visit, so their previous ratings were used when calculating the overall rating. The overall rating remained Good from the previous inspection.
Safe staffing
Inspectors found enough staff with the right skills. People experienced continuity from regular staff who knew them well, and the home did not use agency staff.
“The management team completed a staffing needs analysis, based on people's dependency assessments.” from the report
Safe medicines
Staff gave medicines calmly and safely. Records had no unexplained gaps, staff competency was checked, and medicines were stored securely.
“MARs had been fully completed and had no unexplained gaps.” from the report
Kind and person-centred care
Staff treated people with compassion, respected their choices and adapted communication to individual needs. People were supported to take part in activities and improve their wellbeing.
“Staff always spoke to people with compassion, even if just passing in the hallway on their way elsewhere.” from the report
Good leadership
Managers were approachable and visible. They used audits, reviews and action plans to monitor care and support improvement.
“There were robust measures to monitor quality, safety and the experience of people within the service.” from the report
Good partnership working
The home worked with GPs, nurses and other professionals when people's needs changed. Inspectors found this led to good health outcomes.
“We saw evidence of effective, collaborative working with a broad cross section of health and social care professionals throughout the inspection, which consistently achieved good outcomes for people.” from the report
Falls records lacked detail
needs fixingAlthough falls were recorded and people were referred for support, records did not always explain the causes, contributing factors or how future risk had been reduced. Inspectors recommended further training for management staff.
“Details logged in the care system did not always include enough information about the root cause, factors which contributed to the incident, witnesses, environmental factors, how risk was reassessed or effectively mitigated.” from the report
Different falls-risk levels in records
needs fixingSome care records showed different levels of falls risk in different places. Managers said this was a technical problem with the electronic system and planned to investigate it.
“sometimes stating the person was at high risk of falls and elsewhere in the same record that there was a medium risk of falls.” from the report
Sling laundry records
minorInspectors found clean equipment and individual slings, but it was not clear how often slings were laundered. The deputy manager planned to record this in future.
“It was not clear how often the slings were laundered” from the report
- 01How are falls now investigated, including their causes, witnesses, environmental factors and steps to prevent them happening again?
- 02Has the technical problem causing different falls-risk levels in the same record been fixed?
- 03How do you record and check how often each person's sling is laundered?
- 04What action has been taken following the recommendation for extra management training in accident and incident investigations?
- 05Which caring and responsive ratings from the previous inspection were carried forward into the overall Good rating?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were used for the overall rating. This explanation was written from the published report of 22 September 2022 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, April 2021
Rated Good; inspectors found safe, kind and personalised care, with a small number of records needing review.
This was the home’s first inspection since registration. The unannounced visit took place on 9 April 2021. Inspectors spoke with people living there, relatives and staff, observed communal areas, and checked care, medicines, recruitment and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were protected from abuse and avoidable harm, received skilled care, and were treated with kindness, dignity and respect.
Care plans were detailed and personalised. People and relatives were involved in decisions, and there was a wide choice of activities. Inspectors also found good infection control arrangements during the COVID-19 pandemic, strong oversight by managers and positive feedback from people, relatives and staff.
There were some minor points to improve. A small number of do-not-resuscitate orders needed review, and records about openness when things went wrong were not always clear. The home provided evidence after the visit showing that action had been taken.
Safe care
People told inspectors they felt safe. Risks and incidents were recorded, investigated and used to prevent problems happening again.
“People received safe care. They confirmed this when we spoke with them throughout the inspection.” from the report
Kind and respectful staff
Staff were observed treating people with compassion and respect. People said staff understood their needs and helped them maintain their independence.
“People and relatives described the service as caring and staff as kind.” from the report
Personalised support
Care records included people's preferences, routines and support needs. People and relatives took part in care assessments and reviews.
“All care plans and risk assessments reviewed were clearly individualised to each person's different needs.” from the report
Strong management
The home had clear leadership, regular checks and a culture of learning. Feedback from people, relatives and staff was used to shape the service.
“A very robust system of audits and checks was in place to monitor and review the safety and quality of the care and service.” from the report
Records about openness
minorRecords showing how the home had met its duty to be open and honest after some events were not always clear. The home later reviewed its process and created a log.
“Documentation about the duty of candour steps was not always clear.” from the report
Medicines best practice
minorMedicines were managed safely, but inspectors gave feedback about embedding best practice guidance. The home made minor improvements after the visit.
“The registered manager was receptive of our feedback on embedding best practice guidance.” from the report
- 01How are do-not-resuscitate orders reviewed now, and how will you involve the person and their family in those reviews?
- 02What changes were made to the process for recording duty of candour actions after the inspection?
- 03How do you check that medicines are managed in line with current best practice?
- 04How are care plans updated when a person's food, drink or other needs change?
- 05What activities and communication options are currently available for people who do not want to join group activities?
This was the first planned inspection and covered all five key questions, including infection prevention and control measures during the COVID-19 pandemic. This explanation was written from the published report of 30 April 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 Falkland Grange Care Home
2 rated inspections over a year: the service has held its Good rating throughout.
- September 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2021GoodSafe: GoodEffective: GoodWell-led: Good
- August 2020Inspected but not ratedSafe: Inspected but not rated
- December 2019
Registered with the Care Quality Commission on 9 December 2019.
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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