CQC report explained · a residential care home
What the CQC found at Florence Grogan House Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found suitable staffing, safe medicines management, risk assessments and effective infection prevention measures.
- Effective?
- Good
- This question was not assessed during this inspection.
- Caring?
- Good
- This question was not assessed during this inspection, although inspectors observed personalised support and heard positive feedback from people and relatives.
- Responsive?
- Good
- This question was not assessed during this inspection, although inspectors found that care plans were person-centred.
- Well-led?
- Requires improvement
- The home did not have a registered manager. Inspectors found effective quality assurance systems, but said the lack of a registered manager meant registration conditions had not been fully met.
What inspectors found, December 2020
Rated Good overall, but inspectors found the home was not always well-led because there was no registered manager.
Inspectors visited on 2, 5 and 6 November 2020. They spoke with people, relatives, staff and other professionals. They reviewed care records, medicines records, recruitment files and management information.
The home was rated Good for Safe. Inspectors found people were protected from abuse and avoidable harm. Staffing levels were suitable, medicines were managed safely, risks were assessed and infection control arrangements for COVID-19 were in place.
The home was rated Requires Improvement for Well-led. The registered manager had left in April 2020, and the replacement manager had not yet completed registration. Inspectors said this had not harmed the care provided, but registration conditions had not been fully met.
The overall rating remained Good, the same as at the previous inspection published in May 2018. However, Safe improved from Requires Improvement to Good, while Well-led fell from Good to Requires Improvement.
Safe staffing
Inspectors found staffing levels matched people's needs and staff were available to provide support. Recruitment checks had been completed before staff started work.
“Staffing levels were appropriate to the needs of people living at the home and staff told us there were enough staff.” from the report
Medicines
People were supported to take medicines safely and in a personalised way. Medicines were securely managed and regularly audited.
“People were observed being supported to take their medicines in a supportive, safe and personalised manner.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing COVID-19 infection, including PPE, testing, hygiene and visiting controls.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Person-centred care
Care plans included detailed information about people's needs. People said they were involved in their support and could influence it.
“Support plans were person-centred and went into detail on all aspects of people's needs.” from the report
Learning from incidents
The home recorded falls, analysed them and took further action to reduce the chance of them happening again. Infection control audits also identified actions for improvement.
“Falls were recorded with an analysis and further action to prevent a re-occurrence.” from the report
No registered manager
needs fixingThe registered manager had left and the next manager had withdrawn from the registration process shortly before the inspection. A new manager had been identified, but the registration process was still to be completed.
“The absence of a registered manager had not had an adverse impact on the care provided but the length of time to register a new manager had meant that conditions of registration had not been fully met.” from the report
Safeguarding refresher training
needs fixingMost staff had completed safeguarding training, but the manager planned refresher training for all staff over the following months.
“Most staff had received training in safeguarding although the manager had plans for all staff to receive refresher training over the next few months.” from the report
- 01Has a registered manager now been appointed and completed the CQC registration process?
- 02How are you making sure all staff complete safeguarding refresher training?
- 03How are falls recorded, reviewed and followed up to reduce the risk of repeat falls?
- 04How are relatives being kept informed about visiting, infection control and their family member's wellbeing?
- 05How do your quality audits identify and check that improvements have been completed?
This was a focused inspection of Safe and Well-led, including COVID-19 infection prevention and control; Effective, Caring and Responsive were not newly rated. This explanation was written from the published report of 9 December 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.
What inspectors found, May 2018
Florence Grogan House Residential Care Home was rated Good overall, but inspectors found medicines and some safety arrangements needed improvement.
This was an unannounced inspection on 20 and 22 March 2018. It was the first inspection since the change of ownership. Inspectors spoke with people living there, relatives, staff and a visiting professional. They also observed care and checked records.
The home was rated Good overall. Effective, Caring, Responsive and Well-led were rated Good. Safe was rated Requires Improvement. Inspectors found enough staff, suitable recruitment checks, regular risk assessments and generally safe medicines handling, but some medicines records needed correcting.
The home was described as warm, comfortable and welcoming. People were treated with dignity, supported to make choices and helped to keep in touch with activities and health professionals. Complaints were recorded and investigated, and the manager used audits and action plans to monitor the service.
Staffing and recruitment
Inspectors found enough qualified and experienced staff, with robust checks when new staff were recruited.
“There were enough qualified and experienced staff to ensure that people's needs could be met.” from the report
Kind and respectful care
Staff respected people's dignity, individuality and choices. People were supported to remain independent and take part in activities outside the home.
“We observed that staff protected people's dignity and individuality by respecting their choices and preferences.” from the report
Food and health support
People could choose meals and meal times. Nutrition was monitored, and people at risk were referred to a dietician.
“People had a choice of meals and malnutrition risk assessments were completed monthly.” from the report
Complaints and quality checks
The home had a displayed complaints procedure. Records showed that complaints were investigated, answered appropriately and dealt with.
“The manager kept detailed records of complaints that she had received and the records showed that complaints had been investigated, responded to appropriately, and addressed.” from the report
Medicines records
seriousSome handwritten additions to medicines administration records were not signed. More care was also needed when recording controlled drugs, although the quantities checked were correct.
“However, hand-written additions to the MAR sheets had not all been signed.” from the report
Urine smell
needs fixingAn unpleasant urine smell was found on part of the first floor. The manager said a bedroom carpet would be replaced with washable flooring, but inspectors said this needed attention without delay.
“All parts of the premises looked clean, however there was an unpleasant smell of urine in one area of the first floor.” from the report
Fire drills at night
needs fixingFire drills had been recorded during the day only. The manager said this would be addressed for night staff.
“Regular fire drills were recorded but these had all been held during the day and not for night staff.” from the report
Accident monitoring
minorThe inspector recommended that accident reports should be analysed for patterns, such as whether accidents happened more often at a particular time.
“However, we recommend that the accident reports should be analysed by the manager to find out if there are any trends” from the report
Activities
minorSome people said there was not much to do. The inspector discussed considering fresh activity ideas with the manager.
“Some people who lived at the home told us they didn't think there was much to do” from the report
- 01What changes have been made to ensure every handwritten medicines entry is signed and controlled drugs are recorded accurately?
- 02Has the urine smell been removed, and has the bedroom carpet been replaced with washable flooring?
- 03Have night staff now taken part in fire drills, and how are the results recorded?
- 04How are accident records now analysed for patterns and acted on?
- 05What new activities are available for people who feel there is not much to do?
This was an unannounced inspection covering all five key questions and the overall quality of the home, and it was the first inspection since a change of ownership. This explanation was written from the published report of 3 May 2018 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 Florence Grogan House Residential Care Home
2 rated inspections over 3 years: the service has held its Good rating throughout.
- December 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Florence Grogan House Residential Care Home →
- May 2018GoodSafe: Requires improvementWell-led: Good
Read what inspectors found at Florence Grogan House Residential Care Home →
- October 2017
Registered with the Care Quality Commission on 30 October 2017.
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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