CQC report explained · a nursing home
What the CQC found at Greenacres - Care Home with Nursing Physical Disabilities
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe, there were enough staff, medicines were managed safely and infection control arrangements were effective. Some risk assessments had not been updated to reflect new risks.
- Effective?
- Good
- This question was not rated in this inspection.
- Caring?
- Good
- This question was not rated in this inspection. People and relatives gave generally positive feedback about the care and outcomes.
- Responsive?
- Good
- This question was not rated in this inspection. Inspectors found that some aspects of choice and control had not always been explored.
- Well-led?
- Requires improvement
- Some governance systems had not identified safeguarding concerns or outdated records. Communication with relatives about day-to-day needs also needed improvement.
What inspectors found, June 2021
Greenacres - Care Home with Nursing Physical Disabilities is rated Good overall, but well-led was Requires Improvement because some risks and safeguarding incidents were not recorded or followed up promptly.
Inspectors visited on four dates in May 2021. They spoke with people, relatives and staff, reviewed care and medicine records, and checked how the home was managed. The inspection was prompted partly by concerns about risk management.
People told inspectors they felt safe. There were enough staff, medicines were managed safely, and infection prevention arrangements were effective. Staff understood safeguarding procedures and worked with health professionals when needed.
The main weaknesses were in management oversight. Some risk assessments had not been updated, and three incidents had not been recognised as safeguarding concerns until the inspection. Some choices were not always explored, and relatives said communication about day-to-day needs could be better.
The overall rating remained Good, and Safe remained Good. Well-led fell from Good at the previous inspection to Requires Improvement. The manager had started action plans and a new system to improve recording and review.
People felt safe
People and relatives told inspectors they felt safe. Staff understood how to recognise and report abuse.
“People told us they felt safe and relatives felt their loved ones were safe.” from the report
Enough staff
Inspectors observed enough staff on duty to meet people's needs.
“People told us and we observed there were enough staff on shift to meet people's needs.” from the report
Safe medicines practice
Medicines were given as prescribed. There were protocols for medicines needed only when required, and controlled drugs were managed safely.
“Medicines were managed safely to ensure people received them in accordance with their health needs and the prescriber's instructions.” from the report
Infection control
Inspectors were assured about personal protective equipment, testing, visits, cleanliness and the home's arrangements for preventing and managing outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Working with professionals
Staff contacted health professionals when needed and worked with them to support people's changing needs.
“Staff communicated with the GP, community nurses and other professionals when required.” from the report
Safeguarding incidents were missed
seriousThree incidents were not identified by the home's governance systems as safeguarding concerns. They were reported to the local authority and CQC during the inspection.
“There had been three incidents that had not been identified by the governance systems as safeguarding concerns.” from the report
Risk records were out of date
needs fixingSome risk assessments and care records had not been updated when people's risks or needs changed. The management team said these records would be reviewed.
“We did find some risk assessments that had not been updated to reflect new risks.” from the report
Communication with relatives
needs fixingRelatives were generally positive but said communication about people's day-to-day needs could be better.
“There was a general theme that communicating between the home and people's relatives could be improved.” from the report
Choice was not always explored
needs fixingInspectors found that some everyday choices, such as whether to have a bedroom door open or use the bar area, had not always been discussed.
“There were some aspects of choice and control that had not always been explored with people.” from the report
Repairs were needed
minorThe building needed repair work. The manager described short-term and long-term maintenance plans.
“The building was in need of some repair works.” from the report
- 01Have all risk assessments and care plans now been updated, and how are you checking that they stay current?
- 02What new review and recording system is being used to make sure incidents are recognised and referred as safeguarding concerns when needed?
- 03How will you keep relatives informed about people's day-to-day needs?
- 04How do you make sure people's everyday choices, including room and activity preferences, are discussed and recorded?
- 05Which repair works have been completed since the inspection, and what remains outstanding?
This was a focused inspection of Safe and Well-led; the Effective, Caring and Responsive questions were not rated in this report. This explanation was written from the published report of 16 June 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, March 2019
Rated Good; inspectors found safe, kind and personalised care, with improvements since the previous inspection.
This was an unannounced, planned comprehensive inspection. The inspection visit took place on 28 and 29 January 2019. Inspectors reviewed records, accidents, complaints, audits and feedback, and spoke with people living there, relatives and staff.
Thirty people lived in the 33-bed home. People told inspectors they felt safe and were treated with kindness and respect. Staff knew people's needs, supported their choices and helped them stay as independent as possible.
Inspectors found safe medicines practice, suitable staffing, trained staff and regular involvement from health professionals. Care plans were detailed and regularly reviewed. Complaints were investigated and used to improve the service.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. The previous rating was Requires improvement in October 2017 because some legally required notifications had not been made. Inspectors found this had been corrected.
People felt safe
People said they felt safe with staff and believed help was available when they needed it.
“People spoken with told us that the service provided was good they felt safe living there.” from the report
Kind and respectful care
Inspectors saw staff treating people as individuals and involving them in choices about their care.
“Staff treated people as individuals with kindness and compassion.” from the report
Personalised support
Care records included detailed information about people's health, social and personal needs. Staff reviewed care when needs changed.
“Records we looked at were individualised and contained detailed information and clear guidance about all aspects of a person's health, social and personal care needs” from the report
Safe medicines
Medicines were securely stored and administered by qualified nurses. People said they received them on time.
“Medicines were stored securely within the right temperature to prevent deterioration of medicines.” from the report
Improved management
The home had improved its handling of legally required notifications since the previous inspection. Inspectors found audits and action plans were being used to monitor quality.
“Since the last inspection the registered manager has made the necessary improvements and notify us of event that they must send to us by law.” from the report
Inspectors raised no specific concerns in this report.
- 01The manager said a recruitment drive was under way. What are current staffing levels, and how do you make sure they remain adequate?
- 02How will you involve my relative in regular care reviews and decisions about their daily support?
- 03How do you check that medicines continue to be given on time and recorded correctly?
- 04How do you record and respond when a person's health or care needs change?
- 05What action do you take after a complaint, and how do you share the learning with staff?
This was an unannounced planned comprehensive inspection covering all five areas: Safe, Effective, Caring, Responsive and Well-led. This explanation was written from the published report of 6 March 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.
Every inspection of Greenacres - Care Home with Nursing Physical Disabilities
5 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- June 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Greenacres - Care Home with Nursing Physical Disabilities →
- March 2019Goodup from Requires improvementSafe: GoodWell-led: Good
Read what inspectors found at Greenacres - Care Home with Nursing Physical Disabilities →
- October 2017Requires improvementstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2017Requires improvementstayed Requires improvementEffective: Requires improvement
- December 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 12 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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