CQC report explained · a nursing home
What the CQC found at Haddon Hall Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2023
Rated Inadequate and still in special measures; inspectors found serious safety, staffing and management failures despite safe medicines and some immediate improvements.
This was an unannounced follow-up inspection on 6 and 12 June 2023. Inspectors spoke with people, relatives and staff, and checked care records, medicines records, staff files and management records.
People were not always protected from known risks. Records showed missed repositioning, gaps in fluid monitoring and incomplete action after falls. Staffing levels did not consistently match assessed needs, and some people did not receive care in line with their choices.
The home managed medicines, safeguarding and infection control safely. Staff training and supervision were effective, and relatives spoke positively about the food and the new manager. However, checks and audits did not reliably find or correct problems, and earlier concerns had not all been resolved.
The overall rating remained Inadequate. Safe and well-led were Inadequate, while effective was Requires Improvement. The home remains in special measures, meaning the CQC will continue monitoring it and normally re-inspect within six months.
Medicines
Medicines were administered by trained staff, with regular checks and stock monitoring. The report found medicines were managed safely.
“Medicines were administered by trained staff who received regular checks and direct observation of their practice to ensure medicines were administered safely.” from the report
Safeguarding
Staff knew how to report abuse concerns, and safeguarding incidents had been referred and acted on appropriately.
“Safeguarding incidents had been correctly reported. We found that appropriate actions and referrals to relevant professionals had been made to reduce the risk of re-occurrence.” from the report
Infection control
Inspectors were assured that infection risks were being managed, including the safe use of protective equipment and arrangements for visitors.
“We were assured that the provider was using PPE effectively and safely.” from the report
Staff training and support
Training was relevant and up to date. Staff received regular supervision and competency checks.
“The service had effective systems in place to support and supervise staff.” from the report
Healthcare support
People were referred to healthcare professionals when needed, and professional guidance was included in care plans and followed in practice.
“People were supported to access external healthcare professionals when they needed to.” from the report
Missed safety checks and care
seriousSome people did not receive repositioning as often as their care plans required. Fluid records were incomplete, increasing the risk of dehydration and skin damage.
“Records for people who required regular support with repositioning showed this had not always taken place in the specified time frames.” from the report
Falls were not followed up properly
seriousAfter falls, staff did not always complete required observations or show that planned follow-up actions had happened. This could mean injuries or deterioration were missed.
“We found when people had experienced a fall, staff had not completed post fall observations or monitoring in line with the provider's policy.” from the report
Not enough staff
seriousRotas did not consistently show that the assessed number of staff had been deployed. Relatives and staff reported delays with personal care and concerns about staffing.
“We found the staffing rotas did not consistently demonstrate the assessed number of required staff had been consistently deployed.” from the report
Care did not always match choices
needs fixingRecords showed that care was not always delivered according to people's preferences. One person's records showed six showers in 23 days despite a stated wish for daily showers.
“Records showed people had not always received care in line with assessed need and choice.” from the report
Weak checks and records
seriousAudits failed to identify gaps in monitoring records and incomplete actions after accidents. The provider had not fully addressed concerns from the earlier inspection.
“Systems and processes continued to not always be effective in identifying potential risks.” from the report
Mental capacity records incomplete
needs fixingMental capacity assessments and best interest decisions were not always completed for every relevant aspect of care. Work had started but was not yet shown to be consistent.
“Mental capacity assessments and best interest decisions were not always completed for all aspects people's care.” from the report
- 01What staffing levels are now being used on each shift, and how do you check they match residents' assessed needs?
- 02How do you record and check repositioning, fluid intake and weight monitoring for people at risk?
- 03What happens immediately after a resident falls, and how do you prove that all follow-up actions have been completed?
- 04How are care preferences, such as bathing choices, recorded and checked in daily care?
- 05What evidence can you show that the new monitoring systems and other improvements have become consistent and lasting?
This was a focused follow-up inspection of Safe, Effective and Well-led; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 20 September 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, May 2023
Haddon Hall Care Home was rated Inadequate and placed in special measures after inspectors found unsafe care, poor staffing and weak management systems.
This was an unannounced, focused inspection. Inspectors visited three times, including two evening visits, because of concerns about staffing. They reviewed 19 care plans, medicine records, governance records and three recruitment records. They spoke with people, relatives and staff.
Inspectors found that some people had sore or broken skin that was not always treated properly. Risks linked to drinking, weight loss and swallowing were not always identified or managed. Staffing levels and deployment were not always enough to provide safe and timely care. Safeguarding concerns were not always referred to external professionals.
Management checks had not identified important risks. Staff said they did not feel listened to or respected, and repeated concerns about unsafe care had not been properly investigated. The home was clean, infection control measures were in place, and relatives praised staff for being kind and caring.
The overall rating changed from Requires Improvement to Inadequate. The inspection only assessed Safe and Well-led, while the other question ratings carried over from the previous inspection. The provider took some immediate steps after the visit, but the home was placed in special measures and CQC said it would continue to monitor progress.
Clean and infection control
The home was clean, and inspectors were assured that infection prevention measures and protective equipment were being used appropriately.
“The home was clean and free from malodours throughout.” from the report
Kind and dedicated staff
Relatives consistently spoke positively about the staff's kindness, care and commitment, despite the staffing concerns found.
“Relatives consistently praised the hard-working, kind, caring and dedicated staff.” from the report
Immediate response to findings
After inspectors raised concerns, the provider introduced extra support and training. A later visit found that people's skin was healing and some people had gained weight.
“Immediately after the inspection we contacted the provider. They responded by addressing the safety concerns.” from the report
Skin, nutrition and swallowing risks
seriousSome people had sore or broken skin that worsened because the right care was not always provided. Risks around drinking enough, weight loss and swallowing were also not always recognised or recorded safely.
“Some people had developed sore and damaged skin whilst living at Haddon Hall. The provider and registered manager had failed to ensure they always received the necessary care and treatment to promote their recovery.” from the report
Not enough staff
seriousInspectors found that staff were not always deployed effectively. Relatives and staff reported delays in answering call bells and providing basic care, with agency staff adding to the pressure.
“The provider had failed to ensure the staffing levels were adequate to meet people's needs safely using the systems in place.” from the report
Safeguarding referrals
seriousThe registered manager did not refer all concerns about people's sore and broken skin to external safeguarding professionals.
“The registered manager had failed to ensure safeguarding referrals were made for the people who suffered from sore and broken skin.” from the report
Weak checks and oversight
seriousAudits and daily meetings did not identify important risks, including skin damage and significant weight loss. The service's governance systems were not being used effectively.
“The provider had failed to ensure the governance processes were used effectively to assess and monitor the safety of the care provided.” from the report
Staff concerns not investigated
needs fixingStaff said they had repeatedly raised concerns about unsafe care, but these concerns were not properly investigated. Staff also described feeling unsupported and blamed.
“Staff did not feel listened to, valued or respected.” from the report
Communication with relatives
needs fixingSome relatives said they were not kept well informed when things happened to their family member and had to ask for information.
“Some relatives told us they did not feel there was good communication with them when something happened with their relation.” from the report
- 01How have you proved that skin damage, weight loss, poor fluid intake and swallowing risks are now identified and acted on promptly?
- 02What staffing levels are now in place on evenings and weekends, and how do you check that call bells and care needs are dealt with promptly?
- 03How are agency staff checked for the training needed to support people safely, including safeguarding and the medicine recording system?
- 04What weekly audits and management checks are now being completed, and can you show what they have found and what action followed?
- 05How do you record and investigate staff concerns about unsafe care, and how do you keep relatives informed when something goes wrong?
This was an unannounced focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive carried over from the previous inspection. This explanation was written from the published report of 6 May 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.
Every inspection of Haddon Hall Care Home
6 rated inspections over 7 years: the service has slipped, from Good to Inadequate.
- September 2023Inadequatecurrent ratingstayed InadequateSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Inadequate
- May 2023Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- January 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- September 2019Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- August 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- May 2014
Registered with the Care Quality Commission on 28 May 2014.
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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