CQC report explained · a nursing home
What the CQC found at Gresham Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment checks, safeguarding arrangements and generally safe medicines management. They found some gaps in medicine guidance and records, and some minor cleanliness issues, which were addressed or being improved.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its rating was carried forward from the previous inspection.
- Well-led?
- Requires improvement
- The management team was visible, approachable and had improved its audits. However, records about best-interest decisions, daily care, one-to-one observations and environmental risks were not always complete or detailed enough.
What inspectors found, April 2023
Rated Good overall; inspectors found safe care and improvements since the last inspection, but well-led remains Requires Improvement because some records lacked detail.
This was an unannounced focused inspection. Inspectors visited on 16 and 21 March 2023, reviewed care and medicine records, spoke with people, relatives, staff and healthcare professionals, and checked the home’s management systems.
The home was rated Good for Safe. Inspectors found enough staff, safe recruitment, safeguarding arrangements, generally safe medicines management and effective infection control. They also found that risks were being managed, although some records needed more detail.
The home was rated Requires Improvement for Well-led. Management was visible and approachable, and audits had improved, but records about CCTV, hidden medicines, daily care and environmental risks were not always complete or detailed enough. The overall rating improved from Requires Improvement at the previous inspection, and the provider was no longer in breach of the regulations previously identified.
Enough staff
Inspectors found staffing levels sufficient to meet people’s needs. Staff said sickness was covered, and people said staff were available and helped them feel safe.
“There were enough staff employed to meet people's needs.” from the report
Improved safety systems
The home had systems for managing risks, reviewing incidents and responding to falls. The provider had improved enough to no longer breach the safe care regulation.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 12” from the report
Healthcare cooperation
The home made prompt referrals and followed recommendations from healthcare professionals. Professionals described the management as proactive.
“The service worked well with healthcare professionals and we saw prompt referrals had been made as required.” from the report
Open management
People, relatives and staff described the home as friendly and welcoming. The management team was visible, listened to feedback and used audits to identify improvements.
“The culture in the service was welcoming and friendly.” from the report
Incomplete decision records
needs fixingRecords were not always in place for CCTV use or medicines given hidden in food or drink. The home said these records were updated after the inspection.
“Further improvements were required in relation to MCA and best interest decisions.” from the report
Care notes lacked detail
needs fixingDaily notes and records for people receiving one-to-one observation did not always give enough detail. Environmental risks were managed in practice, but the records did not always show this fully.
“Documentation which was in place sometimes required more detail to ensure people's care needs were robustly recorded and reported on.” from the report
Minor cleanliness issues
minorMost areas and equipment were clean, but inspectors found minor areas needing improvement. These were addressed after the inspection.
“We found most of the premises and equipment to be clean, there were minor areas which needed improving regarding cleanliness.” from the report
- 01How do you now record best-interest decisions for CCTV use and medicines given hidden in food or drink?
- 02How do you check that daily notes and one-to-one observation records contain enough detail?
- 03What checks make sure medicated skin patches are placed on different sites as required?
- 04What actions were taken after the minor cleanliness issues found during this inspection?
- 05How are the improved audits used to check that the remaining record-keeping problems have been resolved?
This was an unannounced focused inspection of Safe and Well-led; the other key-question ratings were carried forward from the previous inspection. This explanation was written from the published report of 14 April 2023 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, April 2022
Gresham Care Home is rated Requires Improvement; inspectors found kind care and enough staff, but concerns about risk records, medicines and oversight.
This was an unannounced, focused inspection on 10 March 2022. Inspectors reviewed Safe and Well-led only. They spoke with people, relatives, staff and health professionals, and checked care, medicine and management records.
The home had enough staff and people described staff as kind and caring. The home was clean and infection control measures were mostly in place. However, some care plans and risk assessments lacked important detail, and repositioning records did not always show that people were moved as often as needed.
Medicine records, recruitment checks and quality audits needed improvement. Safeguarding incidents referred to the local authority had not always been reported to CQC. The overall rating changed from Good to Requires Improvement, and the home breached regulations about safe care and treatment and good governance.
Kind staff
People and relatives said staff were caring and treated people with dignity and respect.
“Staff were observed to be kind and caring, and people living in the service confirmed this.” from the report
Enough staff
Inspectors found sufficient staff on shift. Staff also reported regular supervision.
“Sufficient numbers of staff were provided on shift. Staff we spoke with confirmed this.” from the report
Clean environment
The home was clean and had visitor handwashing and infection control measures in place.
“The home was clean, and there was a sink installed at the entrance of the home for visitors to use.” from the report
Learning from incidents
Accidents and incidents were recorded, and significant events were discussed with staff to support learning.
“There was a system in place where 'significant events' were logged and discussed.” from the report
Risk and repositioning records
seriousSome care records did not explain clearly enough how risks should be managed. Repositioning records did not state the required frequency, creating a concern about skin breakdown.
“Repositioning records did not specify the frequency required. This meant we were concerned people may not be repositioned frequently enough to protect them from the risk of skin breakdown.” from the report
Medicine information
needs fixingRecords for medicines given when needed were not always detailed enough. Some records for creams and other topical medicines also had gaps.
“PRN protocols for 'as required' medicines were not always sufficiently detailed. This included medicines for pain relief and agitation.” from the report
Governance and reporting
seriousAudits did not always find problems, and some safeguarding incidents had not been reported to CQC as required.
“CQC did not always receive notifications about safeguarding incidents at the service.” from the report
Recruitment records
needs fixingRecruitment files did not always contain proof of address or written explanations for gaps in employment.
“Recruitment files did not always provide a proof of address or contain a written explanation for any gaps in employment.” from the report
Mask use
minorInspectors saw some staff not wearing face masks in line with the guidance in place at the time.
“When we arrived, we noticed that one staff member's mask was not covering the nose as well as the mouth.” from the report
- 01How do you now make sure repositioning records state the required frequency and are completed consistently?
- 02What changes have you made to risk assessments for epilepsy, constipation, mental health needs and distress?
- 03How are 'as required' medicines, pain relief and creams now recorded and checked?
- 04What has been done to strengthen recruitment checks and make sure all records are complete?
- 05How do you now identify and report safeguarding incidents to CQC, and what progress has been made on the action plan?
This was a focused inspection of Safe and Well-led only; the other question ratings were carried over from the previous inspection. This explanation was written from the published report of 8 April 2022 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 Gresham Care Home
4 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- April 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
- January 2021Inspected but not ratedSafe: Inspected but not rated
- January 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- January 2017Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- July 2013
Registered with the Care Quality Commission on 3 July 2013.
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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