CQC report explained · a residential care home
What the CQC found at Harbour 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
- Some medicines were not recorded correctly, controlled medicines records did not match the stock held, and some recruitment checks were incomplete. Care plans did not always give safe and accurate instructions.
- Effective?
- Requires improvement
- People at risk of weight loss were not always weighed, monitored or supported effectively. Advice from healthcare professionals was not always followed, and some care reviews were signed off without the necessary checks.
- Caring?
- Good
- This key question was not inspected during this visit. Staff were seen to build positive and caring relationships and to treat people with dignity.
- Responsive?
- Good
- This key question was not inspected during this visit.
- Well-led?
- Requires improvement
- Audits and management oversight did not identify or fix important problems. The report also found that similar record and risk-review concerns had been identified at another service run from the home.
What inspectors found, March 2023
Rated Requires Improvement; inspectors found risks with medicines, care records, nutrition, recruitment and management oversight.
This was an unannounced inspection on 6 March 2023 after concerns about communication, management, staff following advice and medicines. One inspector reviewed three care plans, staff records and other management records. They spoke with people living there, a visitor, staff, managers and healthcare professionals.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were also rated Requires Improvement. Inspectors found problems with medicines records, recruitment checks, care plans, weight monitoring and the way advice from healthcare professionals was followed. They said these problems created an increased risk that people could be harmed.
There were also positive findings. People said they felt safe, staff were caring and there were enough staff to meet assessed needs. The home was clean, people enjoyed the food, and people and families were asked for their views. Caring and Responsive were not inspected during this visit, so their previous ratings were used when calculating the overall rating.
People felt safe
People and visitors told inspectors they felt safe. Staff had safeguarding training and understood how to report concerns.
“People told us they felt safe. Relatives were confident their loved ones were safe.” from the report
Kind relationships
Staff understood people's individual needs and communication styles. Inspectors saw positive and caring relationships between staff and people.
“Staff had built positive and caring relationships with people.” from the report
Clean and personalised home
The premises were clean and well maintained. People could personalise their rooms and use equipment and adaptations to move around.
“The service was clean and well maintained.” from the report
Food and drinks
People enjoyed the food and were offered drinks regularly. Staff supported people to eat and drink in their rooms when needed.
“People were provided with healthy meals which they enjoyed.” from the report
Medicines records
seriousSome medicines were recorded on a handover sheet instead of the proper medicines record. Records for medicines needing stricter control did not match what was held, creating a risk of errors or extra doses.
“This meant that the administration of these medicines was not clearly recorded for all staff to see, as the appropriate record of the medicine's administration had not been completed and this increased the potential risk of additional doses being given.” from the report
Care plans and risks
seriousSome care plans contained contradictory or unsafe instructions. Inspectors found one person was directed to use soap despite needing prescribed emollient creams, and another person's repositioning guidance was contradictory.
“This person's care plan directed staff, incorrectly, to use soap.” from the report
Weight loss support
seriousSeveral people had recently lost weight, but monitoring and follow-up were not reliable. Food and drink records were incomplete and one person had lost a further three kilos without the required monthly weighing.
“There was a lack of robust process and procedures in place for staff and management to follow when people had been identified as having lost weight, or at risk of losing weight.” from the report
Recruitment checks
seriousEmployment gaps and differences between application forms and references were not always investigated. One staff member worked unsupervised for several weeks before references had been received.
“One staff member had worked unsupervised at the service for several weeks with no references having been received from their previous employers.” from the report
Management oversight
needs fixingAudits did not identify important problems with records, care plans and recruitment. Inspectors said action had not always been effective when the provider already knew about concerns.
“The provider and registered manager did not have effective quality monitoring systems in place.” from the report
- 01What has changed in the way medicines are recorded and audited, especially medicines needing stricter controls?
- 02How are people at risk of weight loss now weighed, assessed and supported, and how is this checked by managers?
- 03How do you make sure care plans give clear, current and consistent instructions to staff?
- 04Have all staff recruitment files been checked for employment gaps, matching references and references received before unsupervised work?
- 05What actions are in the provider's action plan, and how will families be told about progress?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were used to calculate the overall rating. This explanation was written from the published report of 28 March 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 2021
Rated Good; inspectors found safe, kind and personalised care, with some medicines and premises records needing improvement.
This was an unannounced inspection on 01 September 2021. One inspector and a pharmacist inspector spoke with six people, one relative and seven staff. They also reviewed care, medicines, recruitment and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe recruitment, suitable care plans, safe infection control and good support from health professionals.
People said they felt safe and well cared for. Staff were seen treating people kindly and respecting their privacy, choices and independence. Activities had been affected by the COVID-19 pandemic and an activity coordinator vacancy, but another coordinator had recently been employed.
People felt safe
People said they felt safe, and inspectors found safeguarding systems and risk assessments were effective.
“People told us they felt safe.” from the report
Kind and respectful care
Staff showed patience and kindness, including when people became anxious or upset. They respected privacy, dignity and personal choices.
“We observed staff patiently and kindly supporting people when they became anxious or upset.” from the report
Personalised support
Care plans described people's likes, dislikes, backgrounds and health needs. Staff knew how people wanted to be supported.
“Care plans were person centred and detailed people's likes and dislikes and how they wanted to receive support.” from the report
Good oversight
The management team used audits, meetings and feedback to monitor care and act when improvements were needed.
“There were effective quality assurance and auditing systems in place designed to drive improvements in the service's performance.” from the report
Some creams were not recorded
needs fixingThe new electronic medicines system did not always record creams and other external medicines. The manager took action during the inspection.
“However, the application of creams and external items were not always recorded on this system” from the report
Refrigerator records were incomplete
minorThe refrigerator temperature was suitable, but the full maximum and minimum range was not being recorded. The manager said this would be corrected.
“However, the full maximum and minimum range was not being recorded.” from the report
Some medicines needed more secure storage
needs fixingMedicines waiting to be returned to the pharmacy were temporarily kept in the manager's office. The home said they would be stored more securely in future.
“some medicines waiting for return to the pharmacy were in the manager's office” from the report
Step outside dining room
needs fixingThe carpet at a step between floor levels could make the change in level hard to judge. The provider had sourced a more suitable floor covering.
“there was a risk people could misjudge the level of the step.” from the report
- 01How do you now record creams and other external medicines, and how do you check these records are complete?
- 02Where are medicines waiting to be returned to the pharmacy stored now?
- 03Are maximum and minimum refrigerator temperatures now recorded, and who checks these records?
- 04What action was completed to make the step outside the dining room easier to see?
- 05How has the activities programme changed since the new activity coordinator was employed?
This was an unannounced inspection covering all five CQC questions, including care, medicines, premises, infection control and management systems. This explanation was written from the published report of 4 November 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 Harbour House
3 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2021GoodSafe: GoodEffective: GoodWell-led: Good
- February 2021Inspected but not ratedSafe: Inspected but not rated
- April 2019GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2018
Registered with the Care Quality Commission on 24 April 2018.
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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10 live-in carers within about two hours of Cornwall
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Most charge £980 to £1,200 a week. 8 can care for a couple. 12 years' experience on average.
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