CQC report explained · a nursing home
What the CQC found at Halvergate House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risks were not always assessed or managed. Inspectors found harmful chemicals accessible to people, insecure grounds, incomplete care information and insufficient suitably trained staff.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- Quality checks did not identify several risks and shortfalls. Record keeping was not good enough to show that care plans were always followed.
What inspectors found, August 2022
Rated Requires Improvement; inspectors found risks in care records, staffing and oversight, although people said they felt safe.
This was an unannounced focused inspection after concerns about safe care and treatment. Inspectors visited on 22 June 2022, spoke with people, relatives and staff, and checked care records, medicines, recruitment files and quality checks.
The home was not always safe. Risks were not always properly assessed or managed. People could access harmful chemicals, the grounds were not secure, records lacked important information and there were not enough suitably trained staff.
The home was also not always well-led. Audits had failed to identify several problems, and care records did not always show that people's needs had been met. The provider had started an action plan, but inspectors said the improvements needed time to become established.
The overall rating fell from Good to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were carried forward.
People felt safe
People told inspectors they felt safe and described staff as nice and friendly.
“Oh yes perfectly safe. Everybody is nice and friendly.” from the report
Safeguarding awareness
Staff knew the safeguarding procedures and understood their responsibility for keeping people safe.
“Staff were familiar with safeguarding practices and procedures. Staff received regular training in safeguarding and understood their role in keeping people safe.” from the report
Safe recruitment
The home carried out recruitment checks, including references and DBS checks.
“Staff were safely recruited, and checks were made on their suitability through references from previous employers and Disclosure and Barring Service (DBS) checks.” from the report
Family visiting
Relatives and friends were able to visit regularly, with protective equipment available.
“People's friends and relatives were able to visit people regularly. Visitors had access to Personal Protective Equipment (PPE).” from the report
Approachable management
Inspectors found the registered manager visible and approachable, and relatives could share their views.
“The registered manager was visible in the service, approachable and took a genuine interest in what people, staff, family, advocates and other professionals had to say.” from the report
Unmanaged environmental risks
seriousPeople could reach harmful chemicals in sluice rooms and the grounds were not secure. This could have allowed people to leave without staff knowing when it was unsafe.
“People had access to harmful chemicals in sluice rooms and the grounds of the service were not secure, meaning people could enter or leave the grounds when it was not safe for them to do so without staff being aware.” from the report
Incomplete care records
seriousCare and daily records did not contain all the information staff needed to provide safe care. Risk assessments were not always detailed or reviewed by all staff.
“People's care records and daily records did not include all the information needed to provide safe care.” from the report
Staffing levels
seriousThere were regular staff shortages, many vacancies and a high reliance on overtime and agency staff. Inspectors said this created a potential risk of harm.
“There was not enough staff on duty to meet people's needs.” from the report
Training gaps
seriousSome staff lacked training for people's specific needs, including diabetes and positive behaviour support.
“Some care staff were lacking training to support people to remain safe with extra needs including diabetes and positive behaviour training.” from the report
Weak quality checks
seriousThe home's audits and monitoring systems did not identify many of the problems found by inspectors. This meant leaders had limited assurance that care was safe and person-centred.
“Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
- 01How many permanent staff and agency staff are currently working on each shift, and how do you decide whether staffing is safe?
- 02Have all staff completed training for diabetes and positive behaviour support, and how do you check that they can use it safely?
- 03Have the fence and other measures to secure the grounds been completed and checked?
- 04How have you corrected the missing information in care records and risk assessments, and how often are these records now reviewed?
- 05What changes have you made to audits so they identify safety risks and care-record problems before they affect people?
This was a focused inspection of Safe and Well-led only; the other three ratings were carried forward from the previous inspection. This explanation was written from the published report of 20 August 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.
What inspectors found, December 2021
Halvergate House is Rated Good; inspectors found safe care and strong management during a focused inspection.
Inspectors visited on 11 August and 25 November 2021. The first visit was unannounced and the second was announced. They spoke with people, relatives and staff, observed care, and checked care, medicine, staff and management records.
The inspection followed concerns about medicines and infection control. Inspectors found people were safe, medicines were stored and given properly, records were completed, and infection prevention measures were in place. The home was clean and well maintained.
People and relatives gave positive feedback. Care plans were detailed and regularly reviewed. Staff knew people's needs, and managers checked the quality of care through audits and reviews.
This was a focused inspection of Safe and Well-led only. Both were rated Good. The other three areas were not inspected, so their previous ratings were used in the overall Good rating.
Detailed care plans
Care plans were accurate, person-centred and regularly reviewed. They gave staff clear instructions about people's individual needs and choices.
“Care plans were accurate and robust; enabling staff to safely support people in a manner in which the person had chosen.” from the report
Safe medicines
Medicines were stored securely and administration was recorded digitally. Staff had medicine training and their competence was checked.
“Medicine management was safe. All medicines were stored securely, and documentation was completed following all administrations.” from the report
Infection prevention
Inspectors were assured that the home had suitable arrangements for preventing and managing infections, including use of protective equipment and testing.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Positive staff and management
People and relatives spoke positively about the staff and management. Inspectors saw staff supporting people safely and respectfully.
“People and their families were positive about the management and staff team and felt they were approachable and would speak to them if they have any concerns.” from the report
Further infection control development
minorInspectors signposted the provider to resources to develop its infection prevention and control approach. This was not described as a breach or an immediate safety risk.
“We have also signposted the provider to resources to develop their approach.” from the report
PRN medicine guidance was still being improved
minorProtocols for medicines given when needed were in place, but the report says they continued to be reviewed and improved for clarity.
“The PRN protocols continued to be reviewed and improved to offer additional clarity to those administering the medicines.” from the report
- 01What changes have been made to infection prevention and control since the inspection?
- 02How are medicines given when needed recorded and checked now?
- 03What were the ratings for Effective, Caring and Responsive at the previous comprehensive inspection?
- 04How does the home check that care plans remain accurate as people's needs change?
- 05How are relatives told about incidents or changes in their family member's support needs?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous comprehensive inspection published on 16 December 2017. This explanation was written from the published report of 21 December 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.
Every inspection of Halvergate House
6 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- August 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2021Goodstayed GoodSafe: GoodWell-led: Good
- December 2017Goodup from Requires improvementSafe: GoodWell-led: Good
- October 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2016Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 5 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
13 live-in carers within about an hour of Norfolk
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 £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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.