CQC report explained · a residential care home
What the CQC found at Hadleigh Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2023
Rated Requires Improvement; inspectors found kind, person-centred care, but medicines were not always stored or managed safely and the provider remained in breach.
This was an unannounced, focused inspection on 21 November 2022. One inspector spoke with people, staff, managers and partner agencies, and reviewed care records, medicine records, recruitment files and quality checks.
People said they felt safe and supported by kind staff who knew them well. Risks were assessed, staffing levels were sufficient, safeguarding arrangements were in place and infection control measures were satisfactory.
The main problem was medicines. Some medicines were not stored securely, instructions for some medicines were incomplete, medicine records were not always accurate and checks did not identify these problems. The home remained in breach of Regulation 12.
The overall rating was Requires Improvement, as were Safe and Well-led. Only Safe and Well-led were inspected this time. The other ratings were carried forward from the previous inspection, so the overall rating remained Requires Improvement.
Kind and person-centred care
People described staff as kind, caring and knowledgeable about them. Inspectors found the culture was focused on meeting people's individual needs.
“The culture of the service was caring and focused on ensuring people received person-centred care that met their needs.” from the report
People felt safe
People who could share their views said they felt safe. Staff had safeguarding training and understood how to report concerns.
“People who were able to share their views told us they felt safe.” from the report
Enough regular staff
Inspectors found there were enough staff to meet people's needs. People were supported by a regular team who knew them well.
“There were sufficient numbers of staff to meet people's needs.” from the report
Positive leadership relationships
People, relatives and staff spoke positively about the management. Staff said they felt listened to, supported and valued.
“Staff told us they felt listened to, were supported and valued by the registered manager, and had an input into the service.” from the report
Medicines were not always safe
seriousMedicines awaiting return to the pharmacy were not stored securely. Some instructions for medicines given when needed were incomplete, and medicine records and stock checks were not reliable.
“Medicines due to be returned to the pharmacy for safe disposal were not stored securely.” from the report
Checks failed to find problems
needs fixingThe home's medicine audits did not identify the unsafe practice. Inspectors said governance systems needed further improvement.
“However, we found improvements were still needed as governance systems had not identified poor practice.” from the report
- 01How are medicines awaiting return to the pharmacy now stored securely?
- 02How do you make sure instructions for medicines given when needed contain enough information for staff to use them safely?
- 03How do you check medicine administration records and stock quantities are accurate?
- 04What changes have you made to medicine audits since this inspection, and what has the latest audit found?
- 05What actions are included in the improvement plan sent to the CQC, and when will they be checked?
This was an unannounced focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 27 January 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, August 2019
Hadleigh Court is rated Requires Improvement; inspectors found kind care but unsafe medicines management and incomplete risk records.
This was an unannounced focused inspection on 09 July 2019. One inspector spoke with people, staff and the manager, reviewed care and medicine records, checked the home, and received feedback from health and social care professionals.
People said they felt safe and supported. Staff were kind and attentive. The home was clean, staffing and recruitment were safe, call bells were answered promptly, and some risks, such as falls, skin care and nutrition, were managed well.
However, one person did not receive a medicine as prescribed. Some medicine records were incomplete. Risk records did not always explain how known risks should be reduced. The checks used by managers had not found these problems.
The overall rating changed from Good to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three question ratings were carried over from the previous comprehensive inspection and were not reviewed during this visit.
Kind and attentive staff
People said they felt safe and supported. Inspectors saw staff being kind, caring and attentive.
“People told us they felt safe, supported and were happy living at Hadleigh Court.” from the report
Some risks managed well
Risks linked to mobility, skin care and nutrition were identified and acted on. Staff sought specialist advice when needed.
“Other risks were well managed.” from the report
Safe staffing and recruitment
The home had recruitment checks and people said there were enough staff. Inspectors saw call bells answered promptly.
“Throughout the inspection we saw call bells were answered promptly, and people did not have to wait for assistance.” from the report
Clean and safer laundry processes
The home was clean, and laundry arrangements had improved to reduce the risk of cross-contamination.
“Laundry processes had sufficiently improved to help prevent the spread of infection and reduce the risk of cross contamination.” from the report
Medicine not given as prescribed
seriousRecords showed that one person did not receive a prescribed medicine in the way directed. Some records for patches and medicines given when needed were also incomplete or inaccurate.
“Staff were not administering this medicine in the way prescribed for them.” from the report
Management checks missed problems
needs fixingThe home's audits and care plan reviews did not identify the medicines and record-keeping problems found by inspectors.
“The systems in place had not been undertaken robustly and therefore had been ineffective in identifying poor practice.” from the report
- 01What action have you taken to ensure every medicine is given exactly as prescribed?
- 02How do you now check records for medicines given when needed, patches and medicines requiring regular monitoring?
- 03How are risks such as choking, smoking and personal relations recorded, and what clear instructions are given to staff?
- 04How often are care records and medicines checked, and who confirms that any problems have been corrected?
- 05What progress have you made in response to the action report required after this inspection?
This was a focused inspection of Safe and Well-led only; the other question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 9 August 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 Hadleigh Court
6 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- January 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- January 2019Goodstayed GoodSafe: GoodWell-led: Requires improvement
- July 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Inadequate
- December 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 3 December 2010.
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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21 live-in carers within about an hour of Torbay
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,400 a week. 17 can care for a couple. 12 years' experience on average.
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Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.