CQC report explained · a nursing home
What the CQC found at Gardenia Court Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2019
Gardenia Court Nursing Home was rated Requires Improvement because inspectors found safety and management weaknesses despite kind, effective and responsive care.
This was an unannounced inspection on the first day and a planned follow-up to the previous rating. Inspectors visited on 17 and 18 April 2019. They spoke with people, relatives and staff, reviewed care and staff records, and checked the home and the care provided.
People generally said they felt safe. Staff were caring, trained and available when needed. Inspectors rated Effective, Caring and Responsive as Good. Care plans were personal, people were supported to access healthcare, and complaints were recorded and investigated.
However, inspectors found risks that had not been properly identified or dealt with. These included unsafe hot water temperatures, trip hazards, incomplete risk assessments and weak checks on the quality and safety of the home. The overall rating changed from Good at the previous inspection to Requires Improvement.
Kind and respectful care
People and relatives described staff as kind and caring. Inspectors found that people were treated with dignity, supported to make choices and encouraged to remain independent.
“People were supported by staff who were kind and caring. People told us, "They are very caring and communicate well. They are very, very good” from the report
Staffing and training
The home had enough staff to meet people's needs. Staff received induction, relevant training, regular supervision and annual reviews.
“People were supported by staff who had received training, supervision and an annual appraisal.” from the report
Prompt help
People had call bells and inspectors saw them answered without delay. People and relatives said staff responded quickly when help was needed.
“People had access to call bells should they need to summon assistance or help. During the inspection we observed these being answered without a delay.” from the report
Personalised care and healthcare
Care plans included people's preferences, interests and support needs. The home made referrals and worked with health professionals when required.
“People's care plans were personalised and individual. They included important information relating to people's behaviours should they become upset or anxious.” from the report
Unsafe hot water
seriousTwelve hot water taps were above the required temperatures, and no action had been taken after earlier checks identified the problem. This could have placed people at risk of burns.
“Maintenance records showed that 12 hot water taps on the 8 April 2019 were above the required temperatures and no action had been taken to rectify the issue” from the report
Incomplete risk assessments
seriousMoving and handling assessments did not explain how some equipment should be used. There were also no risk assessments for people at risk of spilling hot or cold drinks.
“Risk assessments were also required for people at risk of spilling hot or cold drinks.” from the report
Environmental hazards
seriousInspectors found lumpy and fraying carpets, fraying thresholds and equipment stored in communal areas. Some repairs were made after the inspection, but other maintenance work was still needed.
“Some carpets posed a trip hazard to people due to being lumpy and fraying.” from the report
Weak quality checks
seriousThe home's audits had not identified important safety and care-record problems. Inspectors also found a leaking toilet and broken toilet roll holder.
“Systems to monitor and audit the safety and quality of the service was not effective and had not identified the improvements that were required.” from the report
Activities and emotional support
needs fixingPeople felt the choice and quality of activities could improve. Some care plans also lacked clear guidance for staff when people became anxious or upset.
“People felt the quality and choice of activities was variable and could improve.” from the report
- 01What has been done to make sure all hot water temperatures are within safe limits, and how are they checked now?
- 02Have all moving and handling risk assessments been updated with clear instructions for each piece of equipment?
- 03What repairs have been completed for carpets, thresholds, flooring, toilets and other parts of the building?
- 04How do you check that audits identify and fix safety problems before someone is harmed?
- 05What support is now recorded for people who become anxious or upset, and how have activities been improved?
This was a planned inspection covering all five CQC questions, including both the premises and the care provided; the first day was unannounced. This explanation was written from the published report of 11 June 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.
What inspectors found, August 2017
Rated Good; inspectors found safe and attentive care, but some care and accident records lacked detail.
This was an unannounced, focused inspection on 7 July 2017. It followed a notification about a person being scalded by a hot drink. The incident itself was not examined because it was subject to a criminal investigation. Inspectors looked at risks linked to scalding and injury treatment.
Inspectors spoke with people living at the home, staff and a visiting healthcare professional. They reviewed five people's care plans and risk assessments, including wound care and mouth care records. They also checked accident records, training, safeguarding procedures and safety audits.
People said they felt safe. Inspectors found enough staff, prompt responses to call bells, safe support with moving and eating, and suitable precautions for people at risk of scalding. Staff understood people's risks and nursing needs, and accidents and incidents were reviewed.
The overall rating was Good, and the Safe question was also rated Good. Some care plans and accident records did not contain enough detail, although staff and nurses could explain the care and actions needed.
Enough staff
Inspectors found enough staff to meet people's needs. Staff responded promptly and did not appear hurried or rushed.
“There was enough staff to support people safely.” from the report
Safe support
Staff used safe procedures when helping people with meals, drinks and hoists. They also used plastic beakers for people at risk of scalding.
“Hot drinks were in plastic beakers for people who were at risk of scalding themselves.” from the report
Staff knowledge
Staff understood people's current risks and how to support them. Nurses could explain people's nursing care, including wound treatment.
“The registered nurses were able to tell us exactly how they care for the person concerned.” from the report
Learning from incidents
Accidents and incidents were reviewed, and staff were told about risks and actions at handover meetings.
“Accidents and incidents which involved people living at the home were analysed and learning took place.” from the report
Incomplete care records
needs fixingSome care records did not explain all the details needed for safe care, such as what should be used to clean a wound or how to change and reapply a dressing.
“There was a lack of detailed information in certain care plans and risk assessments.” from the report
Accident records lacked detail
needs fixingRecords did not always show clearly what action had been taken after an accident to reduce future risk. The registered manager and staff could explain the action, but it was not always written down.
“It was not always clearly recorded what action had been taken following an accident to reduce the risk.” from the report
- 01How will you make sure every care plan explains exactly how wounds should be cleaned and dressings changed?
- 02How do you record the actions taken after an accident or near miss, and how do you check that risks have been reduced?
- 03What safeguards are now in place for people who may be at risk of scalding from hot drinks?
- 04How are staff told about changes to people's risks and care needs between written record updates?
- 05What learning and changes followed the scalding incident mentioned in the report?
This was an unannounced focused inspection of Safe only; the other question ratings were not assessed in this report. This explanation was written from the published report of 5 August 2017 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 Gardenia Court Nursing Home
6 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- June 2019Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2017Goodstayed GoodSafe: Good
- June 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- September 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvement
- May 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- August 2011
Registered with the Care Quality Commission on 2 August 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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