CQC report explained · a residential care home
What the CQC found at Grove House Residential Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2023
Rated Requires Improvement; inspectors found serious gaps in risk management, fire safety and oversight, despite kind staff and people feeling safe.
This was an unannounced inspection on 16 January 2023 by two inspectors. They spoke with seven people, one relative and eight staff. They reviewed care, medicine and recruitment records, along with checks on quality and safety.
Inspectors found that risks were not always properly assessed or managed. These included falls, catheters, smoking, hot water, unsafe window restrictors and fire safety. Some medicines records and infection control practices also needed improvement.
People said they felt safe and spoke positively about staff. Inspectors found enough staff, safe recruitment, kind and respectful care, and support for people's choices and relationships.
The overall rating remains Requires Improvement. Safe and Well-led were both rated Requires Improvement. The home has had this rating for five consecutive inspections. The provider must send an action plan, and CQC will monitor progress with the local authority.
Kind and respectful staff
People and relatives spoke positively about the staff. Inspectors observed kind, considerate care that respected people's dignity.
“Staff interacted with people in a kind and considerate manner, treating them with dignity and respect.” from the report
Staff available
Inspectors found enough staff to provide the care people needed. Staff were recruited safely.
“There were enough staff available to provide the care and support people required.” from the report
People felt safe
People said they felt safe, and staff understood their safeguarding responsibilities. People received their medicines as prescribed, although medicines management systems still needed improvement.
“People felt safe in their home.” from the report
Partnership working
Staff worked with health and social care professionals to support people's health and wellbeing.
“The management team and staff worked in partnership with a range of healthcare professionals to support people to maintain their health and well-being and achieve positive outcomes.” from the report
Risks were not managed
seriousRisk assessments and guidance were missing for falls, catheters and smoking. Environmental and fire safety risks had also not been dealt with promptly.
“Systems and processes were not sufficient to demonstrate risk was identified, assessed and well-managed.” from the report
Fire and environmental safety
seriousSome fire safety actions identified in June 2022 were still incomplete. Unsafe window restrictors, excessive hot water temperatures and a faulty tap also created risks.
“Fire safety risks were not managed safely.” from the report
Medicines systems
needs fixingSome creams were not securely stored or dated, risks from flammable creams had not been assessed, and instructions for some as-required medicines were missing.
“Some aspects of medicines management required improvement to ensure medicines were consistently managed safely in line with the provider's procedure and best practice guidance.” from the report
Weak quality oversight
seriousAudits did not identify all the problems found by inspectors, and action on known shortfalls was not timely. Some care records were incomplete or out of date.
“The provider had failed to effectively assess, monitor and mitigate risks associated with the health, safety and welfare of people.” from the report
Infection control practice
minorThe home was clean and most infection control arrangements were satisfactory. However, storing toilet rolls on toilet cisterns and leaving toiletries unlabelled created a risk of cross infection.
“The storage of toilet rolls on top of toilet cisterns and unlabelled toiletries in communal toilets was poor practice and created the risk of cross infection.” from the report
- 01What has been done to complete the outstanding fire safety actions identified in June 2022?
- 02Have individual risk assessments now been completed for falls, smoking and catheter care?
- 03How are water temperatures, window restrictors and other environmental risks being checked and repaired?
- 04How are medicines audits now checking creams, as-required medicines and staff competency?
- 05What changes have been made to ensure care records are complete, up to date and acted on promptly?
This was a focused inspection of Safe and Well-led only; the other three key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 10 February 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, November 2019
Grove House Residential Care Home was rated Requires Improvement; inspectors found kind, effective care but gaps in safety checks and quality monitoring.
This was an unannounced comprehensive inspection on 5 November 2019. Inspectors spoke with people living at the home, a relative, staff and a health professional. They also checked care records, medicines, staff files, complaints and quality audits.
People said they felt safe and received kind, personalised care. Medicines were managed safely. Staff were trained, responsive and respectful. People had choices about their care, food, activities and daily routines.
Inspectors found that some safety checks were not reliable. One air-filled mattress was deflated and it was unclear whether another mattress was self-regulating. Wardrobes had not been secured to walls, and the emergency plan needed more detail.
The overall rating was Requires Improvement. Safe and well-led were Requires Improvement, while effective, caring and responsive were Good. The home had improved since the previous inspection and was no longer in breach of regulations, but the improvements needed more time to become consistent.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff respecting privacy, dignity, independence and personal choices.
“People and relatives described staff as respectful, gentle and kind.” from the report
Improved medicines management
Medicines were stored, administered and disposed of safely. Staff training and checks supported safe administration.
“Significant improvements had been made in all areas of medicine management which meant medicines were managed, stored, administered and disposed of safely.” from the report
Personalised care
Care plans contained current information about people’s needs, preferences and choices. Staff used this information in day-to-day care.
“Care plans were personalised, detailed and up to date.” from the report
Improved staff support
Staff had completed training, received support and understood people’s specific needs. Staffing levels were adjusted according to people’s dependency needs.
“Staff training was up to date. Staff had also completed additional training specific to the needs of people living at the home.” from the report
Mattress safety checks
seriousInspectors could not confirm whether one air-filled mattress was self-regulating. Another mattress was found deflated after being unplugged, and it was unclear why or when this had happened.
“Despite the manager having sought advice about mattress types and settings, it was not clear if one mattress in use was self-regulating.” from the report
Environmental checks
needs fixingChecks had not identified that wardrobes in bedrooms were unsecured. The manager acted immediately when inspectors raised this, but the failure showed that safety checks were not always effective.
“Environmental checks had not identified wardrobes in people's bedrooms were not secured to the wall which presented a risk.” from the report
Quality monitoring not fully embedded
needs fixingThe home had introduced more audits and checks, but some did not identify important risks. Inspectors said more time was needed to show that improvements would continue.
“Audits are still work in progress as they now need to be embedded.” from the report
No registered manager
minorThe home did not have a manager registered with CQC during the inspection. A manager was in post and was planning to apply for registration.
“The service did not have a manager registered with the Care Quality Commission.” from the report
- 01How do you now confirm that every air-filled mattress is correctly set up and remains inflated?
- 02How often are bedroom furniture and other environmental risks checked, and who reviews the results?
- 03What changes have been made to the emergency plan for people who cannot return after an evacuation?
- 04How have the new quality audits been embedded, and can you show recent examples of actions taken?
- 05What is the current position on the manager’s application to register with CQC?
This was an unannounced comprehensive inspection covering all five CQC questions, the care provided and the premises. This explanation was written from the published report of 26 November 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 Grove House Residential Care Home
6 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- February 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Grove House Residential Care Home →
- November 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Grove House Residential Care Home →
- August 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- May 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 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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