CQC report explained · a nursing home
What the CQC found at Ghyll Royd Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found systems to protect people from abuse, assess risks, manage medicines and prevent infection. They also found that improvements had been made to information gathered during admissions.
- Effective?
- Good
- This area was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Well-led?
- Good
- Inspectors found regular audits, supportive management and a process for reflective practice and sharing good practice.
What inspectors found, August 2021
Rated Good; inspectors found safe care and strong management, with a medicines storage issue corrected during the visit.
This was an unannounced focused inspection. Inspectors visited on 13 July 2021 and continued their inspection activity until 29 July 2021. They spoke with people, relatives and staff, and checked care, medicines, risk and quality records.
The home was rated Good overall. Safe and Well-led were both rated Good. Inspectors found that people were protected from abuse, medicines were given safely, infection controls were in place and there were enough staff observed to meet people's needs.
The inspection was prompted by concerns about admissions, nutrition and hydration, medicines, COVID-19 arrangements and management oversight. Inspectors found no evidence that people were at risk of harm from these concerns. They found improvements in the information collected when people were admitted.
This inspection only checked Safe and Well-led. The other areas were not inspected, so their previous ratings were used in the overall rating.
Safe medicines management
Medicines were ordered, stored, recorded and given safely. All 15 medication records checked were complete and accurate.
“Medicines were ordered, stored, recorded and administered safely.” from the report
Protection from harm
Staff had safeguarding training and knew how to report abuse. People and relatives told inspectors they felt safe.
“People and relatives, we spoke with told us they felt safe at Ghyll Royd.” from the report
Infection control
The home had up-to-date infection control procedures and inspectors were assured about testing, protective equipment, hygiene and safe admissions.
“We were assured that the provider's infection prevention and control policy was up to date.” from the report
Supportive leadership
People, relatives and staff spoke positively about the management. The home used audits and reflective practice to monitor and improve care.
“The provider and manager had systems in place to monitor, manage and improve service delivery and support provided to people.” from the report
Kind and compassionate care
Inspectors observed staff supporting people with dignity and comfort. People and relatives also described staff as kind and caring.
“People were supported with dignity and compassion. For example; one person became tearful at the dining table, the nurse sat with the person and comforted them.” from the report
Medicine storage
needs fixingA large yellow bag containing medicine bottles was found on the medicines room floor. Staff corrected this after the inspector raised it.
“We spoke to the nurses on shift around the disposal of medicines in the home due to the fact we found a large yellow bag of bottles were on the medicines room floor.” from the report
Mixed views about staffing
minorInspectors observed enough staff and timely care, but one person and one relative felt the home could sometimes use more staff.
“However, we received mixed views from people and relatives.” from the report
Limited recent feedback survey
minorThe home had not completed another survey since the previous inspection published in February 2021. It did communicate with families by email, telephone and newsletters.
“The service had not completed another survey since the last inspection which was published in February 2021.” from the report
- 01How do you now make sure medicines waiting for disposal are stored safely and kept off the medicines room floor?
- 02How do you check that there are enough staff on each unit during busy periods and overnight?
- 03What changes have you made to the information collected before a person moves into the home?
- 04How do you gather families' views now that another survey had not been completed since February 2021?
- 05How do you use reflective practice and audits to identify and correct problems?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 11 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, February 2021
Ghyll Royd Nursing Home was rated Good; inspectors found safe, kind care, but care records and some monitoring records needed improvement.
This was a focused inspection. Inspectors looked mainly at Safe, Responsive and Well-led, after concerns about falls, medicines, management, Covid-19 and leadership. They visited on 26 November 2020 and reviewed information and records until 26 January 2021.
Inspectors found people were safe, medicines were managed properly, staffing levels were enough and infection controls were generally effective. People and relatives said staff were kind, supportive and knew people well. Complaints were handled appropriately and the service had systems to monitor quality.
There were some weaknesses. Risk charts were not always completed fully, care plans did not always contain enough personal detail, and some audit records did not clearly show when actions had been completed. These issues were addressed or planned for during the inspection. The overall rating was Good, the same as at the previous inspection.
Safe medicines
Medicines were stored securely, audited and given in the right way.
“Records showed that people were given their medicines in the right way.” from the report
Enough staff
Inspectors found enough staff to meet people's needs. People and relatives said call bells were answered promptly.
“There were enough staff to meet people's care and support needs.” from the report
Kind relationships
Staff were described as caring and supportive. Inspectors saw positive interactions and said staff did not rush people.
“Staff interactions were positive, and kind. Staff took their time with people and did not rush them.” from the report
Activities and choice
People could choose whether to join activities. Activities were planned around people's needs and interests.
“People choose whether to participate in activities and staff respected their decision.” from the report
Complaints handled
The home recorded complaints, tracked actions and used them to identify learning.
“Complaints were used to identify any areas of learning, so action could be taken to reduce the risk of reoccurrence.” from the report
Incomplete risk charts
needs fixingCharts for repositioning, fluid intake and personal care were not always completed in full. The manager addressed this during the inspection.
“However, charts to support risk management such as change of position, fluid intake and personal care delivered were not always completed in full.” from the report
Care plans lacked detail
needs fixingSome care plans used broad phrases such as full support and did not fully describe people's individual needs. The home planned to introduce an electronic system.
“People's needs were not always fully documented in a way that supported a person-centred approach.” from the report
Audit records
minorSome records did not clearly show completion dates or sign-off for actions. The manager agreed to review this.
“There were some inconsistencies with recording completion dates and associated confirmation of sign off from actions completed.” from the report
Covid glove guidance
needs fixingStaff did not always follow government guidance on wearing gloves. This was addressed during the inspection.
“However, we noted staff did not fully follow government guidance on the wearing of gloves.” from the report
- 01How do you now make sure repositioning, fluid intake and personal care charts are completed fully?
- 02How detailed are care plans now, and how will they reflect my relative's individual needs rather than broad terms such as full support?
- 03Has the electronic care planning system been introduced, and what difference has it made?
- 04How do you check that audit actions have completion dates and clear sign-off?
- 05Who is currently managing the home, and has the application for registered manager status been completed?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected, so previous comprehensive inspection ratings were used in calculating the overall rating. This explanation was written from the published report of 24 February 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 Ghyll Royd Care Home
4 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- August 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2021Goodstayed GoodSafe: GoodWell-led: Good
- January 2018Goodup from Requires improvementSafe: GoodResponsive: GoodWell-led: Good
- October 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 7 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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