CQC report explained · a nursing home
What the CQC found at Green Acres Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2021
Rated Requires Improvement; inspectors found safe care and major recent progress, but leadership improvements had not yet been shown to last.
This was a focused inspection on 9 and 29 December 2020. Inspectors spoke with two people living at the home, six relatives and six staff. They reviewed care records, medicines records, staff files, training information and quality checks.
The home was rated Good for Safe. Medicines were managed safely, risks were assessed, staffing was sufficient and infection control arrangements were in place. Minor medicines recording issues were found, but they had not affected people receiving their medicines.
The home was rated Requires Improvement for Well-led. A new manager and deputy manager had made significant improvements in about five months. However, inspectors had not yet seen enough evidence that good leadership and improved record keeping would continue over a longer period.
The overall rating remained Requires Improvement. This focused inspection only looked at Safe and Well-led. Ratings for the other areas were carried forward from the previous comprehensive inspection.
Safer medicines
Medicines systems had improved and people were receiving their medicines when they should. Staff training and competency checks were in place.
“Significant improvements had been made and medicines were managed safely.” from the report
Risk management
Risks were assessed and care plans included steps to reduce those risks. Accidents and incidents were reviewed so lessons could be identified.
“Risks had been assessed and associated care plans contained information to mitigate the risks to people, to keep them as safe as was practically possible.” from the report
Infection control
The home had PPE, staff training, cleaning systems and a separate visiting area. Inspectors found that infection outbreaks were effectively prevented and managed.
“Infection outbreaks were effectively prevented and managed.” from the report
Recent improvement
The new manager and deputy manager had made major changes in a short time. Staff and relatives said care and staff morale had improved.
“The new manager had made significant improvements in a short space of time and concerns and complaints from stakeholders had reduced.” from the report
Positive staff culture
Staff said they worked well together and felt supported. Relatives said they had confidence in the manager and that their relatives were happy at the home.
“Staff morale at the home had improved.” from the report
Leadership not yet proven over time
needs fixingInspectors found important improvements, but these had happened over a relatively short period. They wanted evidence that high-quality leadership would remain consistent.
“There was not yet evidence of sustained, high quality leadership over time.” from the report
Record keeping
needs fixingSome care records, moving and handling records and medicines records were not consistently clear or complete. Some issues had not been identified by the home's own audits.
“There were some areas identified at inspection which required improving which had not been picked up at audit such as the consistency and clarity of some care intervention records, moving and handling records and medication records.” from the report
Communication with relatives
minorCommunication had improved, but some relatives still wanted more involvement in helping the home improve.
“Some relatives said that although communication had improved, this was an area that could improve further with some actively wanting to be involved to help the service to improve.” from the report
Minor medicines recording issues
minorInspectors found small problems with medicines records, although these had not affected people receiving their medicines.
“There were minor issues identified relating to record keeping, but this had not impacted on people receiving their medicines.” from the report
- 01What checks are now in place to make sure care intervention records and moving and handling records are complete and consistent?
- 02How will you show that the recent improvements in leadership and care quality are being sustained over time?
- 03How are medicines records checked and corrected when minor recording errors are found?
- 04How can relatives receive updates and become involved in suggesting improvements?
- 05Which ratings were carried forward from the previous comprehensive inspection rather than assessed during this visit?
This was a focused inspection of Safe and Well-led, including infection prevention and control; Effective, Caring and Responsive were not assessed and their previous ratings were carried forward. This explanation was written from the published report of 23 January 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 2020
Requires Improvement; inspectors found kind and responsive care, but medicines safety, staffing and management systems needed improvement.
This was an unannounced routine inspection on 7 and 8 January 2020. Inspectors spoke with six people, three relatives and nine staff. They reviewed care records, medicine records, staff files and management records.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were also Requires Improvement. Caring and Responsive were rated Good.
Inspectors found medicines were not always managed safely. Heavy use of agency staff affected communication and the timeliness and organisation of care. Some staff training was out of date, and oral care records were incomplete.
People were generally treated with kindness and respect. Care plans contained detailed information about people's needs and preferences, food was generally well received, and complaints were investigated. This was the home's first inspection since registration.
Kind and respectful care
People and relatives described staff as caring. Inspectors observed staff treating people with kindness and compassion, and found that people were involved in decisions about their care.
“We observed this to be the case during the inspection with staff treating people with kindness and compassion.” from the report
Personalised care planning
Care plans recorded people's needs, likes and preferences. They were reviewed regularly and helped staff provide person-centred care.
“Clear information was recorded on people's care needs, likes and preferences.” from the report
Food and nutrition
People had a choice of food and drink. Inspectors saw that weights were monitored and action was taken when weight loss was identified.
“People had access to a good choice of food and drink each day.” from the report
Handling complaints
The home logged and investigated complaints, responded within appropriate timescales and used action plans to learn from concerns.
“We saw evidence of thorough investigations with action plans produced to ensure learning took place.” from the report
Medicines were not always safe
seriousInspectors found missing evidence that prescribed creams had been given, a controlled medicine had been given too often, and a person was not always offered medicines later in the day. This led to a breach of Regulation 12.
“Medicines were not consistently managed in a safe or proper way.” from the report
Heavy reliance on agency staff
needs fixingAgency staff use affected communication, knowledge of people's needs and the timing of care. On one morning, late agency staff meant staffing levels were reduced and one person was not appropriately supervised.
“We observed one person was not being appropriately supervised and was entering other people's rooms.” from the report
Training needed updating
needs fixingSome staff training was out of date. A plan was in place to address this, but inspectors rated the service Requires Improvement for Effective.
“Staff received a range of training, however some of this was not up-to-date.” from the report
Oral care records were incomplete
needs fixingSome people did not have oral health assessments, and inspectors found a toothbrush that appeared unused with no record that oral care had been provided.
“We found one person's toothbrush appeared unused that day in a drawer, and records did not indicate oral hygiene had been provided.” from the report
Management checks needed strengthening
needs fixingAudits and checks were in place but did not give enough oversight of medicines and training. Care entries were sometimes late, making it harder to investigate whether care was delivered on time.
“Systems and processes were in place to audit and check the service although some of these needed to be made more robust.” from the report
- 01What changes have you made to medicines management since the inspection, particularly for creams, controlled medicines and medicines missed when someone is asleep?
- 02How many agency staff are now being used, and how do you make sure they know each person's needs before providing care?
- 03Which staff training was out of date, and has all required training now been completed?
- 04How do you check and record oral care for every person?
- 05What has changed in the quality checks and clinical oversight since the new manager took over?
This was an unannounced routine inspection covering all five CQC questions; it was the home's first inspection since registration. This explanation was written from the published report of 12 February 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.
Every inspection of Green Acres Care Home
2 rated inspections over a year: the service has held its Requires improvement rating throughout.
- January 2021Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2020Requires improvementSafe: Requires improvementWell-led: Requires improvement
- January 2019
Registered with the Care Quality Commission on 17 January 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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