CQC report explained · a residential care home
What the CQC found at Grenville Court Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- There were enough trained staff, and safeguarding and infection control had improved. However, some risks, an incident and medicine-record problems were not identified or managed properly.
- Effective?
- Good
- This key question was not assessed during this focused inspection. Its previous rating was carried forward.
- Caring?
- Good
- This key question was not assessed during this focused inspection. Its previous rating was carried forward, although inspectors observed patient and kind interactions.
- Responsive?
- Good
- This key question was not assessed during this focused inspection. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- A new management team and better oversight had driven improvement. However, audits and checks still failed to identify some safety and reporting problems.
What inspectors found, May 2021
Grenville Court Care Home is rated Requires Improvement; inspectors found kind care and major progress, but some safety, medicines and monitoring checks were still not reliable, and the home is no longer in special measures.
This was an unannounced focused inspection. Inspectors visited on 12 April 2021, spoke with people, staff, relatives and the manager, observed care, and checked care, medicines, recruitment and management records.
The home had improved since its previous Inadequate rating. There were enough staff, staff had the required checks and training, people were safeguarded, and the home and equipment were clean. People and relatives said they were happy, and inspectors saw respectful, patient and kind care.
Some risks were still not identified or managed properly. Keys had been left in cabinets containing potentially harmful items, one incident had not been reported for investigation, and medicines records had gaps. Audits had not found these problems, so the new systems were not yet fully established.
The ratings for Safe and Well-led were Requires Improvement. The other three key question ratings were not examined during this inspection and were carried forward from the earlier comprehensive inspection. The home is no longer rated Inadequate or in special measures, and the provider was no longer in breach of the regulations at this inspection.
Kind and respectful care
People and relatives were happy with the care. Inspectors saw staff showing patience and kindness.
“Staff were respectful and demonstrated patience and kindness.” from the report
Enough trained staff
Inspectors found enough staff to meet people's needs and keep them safe. Staff had completed training and the required recruitment checks had been carried out.
“There were enough staff to keep people safe and meet their needs.” from the report
Improved management
The new management team and structure had helped improve care, communication and staff support.
“The provider had implemented a new management team and structure to drive improvement within the service.” from the report
Better safeguarding
Staff understood how to report abuse concerns, and safeguarding incidents were reported to the relevant authorities.
“Systems had been improved to safeguard people from the risk of abuse.” from the report
Clean home and infection controls
The home and equipment were clean, and inspectors were assured that several infection prevention measures were in place.
“The home and equipment people used was clean.” from the report
Access to potentially harmful items
seriousKeys had been left in locked cabinets containing items that could cause harm if swallowed. The risks had not been assessed before inspectors raised the issue.
“The keys to the cabinets remained within the lock which meant people may have been able to gain access to these items.” from the report
Medicine records
needs fixingTwo people's cream records had gaps, some medicine information had not been updated, and a medicated patch had not been rotated as advised. Immediate action was taken about the patch.
“Two people's cream records contained recent gaps which implied they had not received them.” from the report
Incident reporting
seriousOne incident had not been brought to the manager's attention. It was therefore not investigated and risks were not reviewed at the time.
“We identified an incident that had not been brought to the manager's attention.” from the report
Management checks
needs fixingAudits and checks had not found some important issues, including the unsecured cabinet keys and the unreported incident. The provider was asked to review its governance systems.
“Some audits and checks had not been fully effective at identifying potential issues for investigation.” from the report
- 01How do you now check that all creams, patches and other medicines have been given and recorded correctly?
- 02What safeguards are in place to stop people accessing toiletries, denture cleaner or other potentially harmful items?
- 03How are incidents reported, investigated and used to update people's risk assessments?
- 04What audits are carried out, and how do you check that they identify problems before inspectors do?
- 05What improvements have been made since the previous Inadequate inspection, and how will you show that they are being maintained?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 20 May 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, November 2020
Previous overall rating Inadequate; a targeted inspection found serious safety and management failures had not been fixed.
This was an unannounced targeted inspection on 8 September 2020. Inspectors checked whether the home had carried out actions promised after serious concerns at an earlier inspection. Two inspectors visited the home and another inspector worked remotely. They spoke with staff and managers, looked at care records, medicines records, food and fluid charts, and repositioning records.
Inspectors found unsafe medicines practice, including staff giving medicines without competency checks and medicines being given at the wrong times. Many agency staff had not had an induction and did not have enough information about residents. There were also problems with emergency arrangements, dietary needs, pressure ulcer care, risk assessments and records.
The provider had not properly checked that its action plan was being followed or that changes were working. The home remained in breach of regulations on safeguarding, safe care and treatment, and good governance.
The overall rating shown for this inspection is Inspected but not rated. This was because it was targeted and did not assess the full service. The previous overall rating was Inadequate and remained unchanged.
Management changes
The provider removed some members of the management team and put an operations director in place to continue work on the action plans.
“The provider again took immediate action to remove some of the management team on site and placed an operations director in place to continue to move the action plans forward.” from the report
Outside support
The home was working with professional groups and the local authority safeguarding team while improvement work was being considered.
“We were working with professional stakeholder groups who had begun to visit the home to support improvement and we were working with the Local Authority safeguarding team to review concerns.” from the report
Unsafe medicines
seriousStaff administering medicines had not had their competence checked. Medicines were given together or too close to the required interval, and records had gaps and unexplained changes.
“Medicines were not safely administered, recorded or managed. This is a breach of regulation 12 (Safe Care and treatment) of the Health and Social Care Act (regulated activities) regulations 2014.” from the report
Insufficient staff preparation
seriousThe home relied heavily on agency staff who had not received an induction. Some staff did not know residents, their rooms or their care needs.
“The provider had not assured themselves the staff on duty were competent in their role. They had not assured themselves staff had the information and training required to meet people's needs and keep them safe.” from the report
Risks to health and safety
seriousRisk assessments were not always updated. Staff did not have reliable information about choking risks, emergency evacuation, first aid or fire safety.
“The provider did not have systems in place to identify, manage and mitigate risks to people living in the home.” from the report
Nutrition and pressure ulcer care
seriousPeople's dietary requirements were not always followed. Food and fluid records were incomplete or inaccurate, and people at risk of pressure ulcers were not always repositioned or supported properly.
“The records for those that required repositioning to protect their skin integrity or reduce risks to already developed pressure ulcers had not been repositioned as required.” from the report
Safeguarding failures
seriousThe provider did not make safeguarding referrals when required and had not delivered the safeguarding training it had promised.
“The provider did not have procedures in place to ensure people were protected from abuse and neglect.” from the report
- 01How are you now checking that every member of staff, including agency staff, has completed an induction and understands each resident's needs?
- 02How do you check that medicines are given at the prescribed times by staff whose competence has been tested?
- 03What has changed to make sure food textures, drink thicknesses and special dietary requirements are followed every time?
- 04How do you now monitor repositioning, pressure ulcer care, food and fluid records, and act promptly when records show a risk?
- 05What evidence can you show that emergency shifts have a trained first aider and fire marshal, and that staff understand evacuation plans?
This was a targeted inspection of specific concerns within Safe and Well-led; the full five key questions were not assessed and the previous ratings were carried forward. This explanation was written from the published report of 12 November 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 Grenville Court Care Home
7 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- May 2021Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2020Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- October 2020Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- December 2019Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- November 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2018Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: InadequateResponsive: InadequateWell-led: Inadequate
- February 2018Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: InadequateResponsive: InadequateWell-led: Inadequate
- May 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016
Registered with the Care Quality Commission on 18 July 2016.
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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