CQC report explained · a nursing home
What the CQC found at Hartshead Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about infection prevention and control, including cleaning, protective equipment, testing, admissions and visiting arrangements. They also reviewed staffing pressures linked to COVID-19.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Requires improvement
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, February 2022
Inspected but not rated; inspectors found good infection-control and visiting arrangements, while staffing pressures were reviewed.
This was a targeted inspection on 28 January 2022. It looked mainly at infection prevention and control, visiting arrangements and staffing pressures linked to COVID-19. The visit was announced four hours beforehand.
Inspectors found enhanced cleaning, suitable areas for indoor and outdoor visits, and a dedicated infection prevention and control champion. They were assured that the home was using protective equipment safely, arranging testing and managing infection risks.
Staffing pressures had been raised with the inspectors. The provider said it used consistent agency staff, extra shifts from managers and staff, and other measures to reduce the effect on people.
The service was inspected but not rated. The report gives a finding for Safe as inspected but not rated, rather than giving a full overall quality rating.
Clean surroundings
The home had enhanced cleaning arrangements and inspectors found it clean throughout.
“There were enhanced cleaning regimes and the home was clean throughout.” from the report
Visiting arrangements
The home provided indoor and outdoor areas for visits, as well as video and phone calls, to help families stay in contact.
“An indoor visiting area as well as an outdoor summer house were used for visitors to minimise the risks of COVID-19.” from the report
Infection-control leadership
A named infection-control champion supported testing and helped staff and visitors follow current guidance.
“There was a dedicated infection prevention and control champion who ensured visitors and staff worked within current guidance to help prevent the spread of infection.” from the report
Staffing pressures
needs fixingInspectors had received information raising concerns about staffing. The provider described using agency staff and additional shifts to manage the pressure.
“We received information of concern about staffing at this service.” from the report
- 01How are staffing pressures affecting care now, and how many agency staff are currently being used?
- 02Are the same agency staff members still being used regularly, and how are they introduced to my relative's needs?
- 03What visiting arrangements are currently available, including indoor, outdoor, video and phone visits?
- 04How are staff, visitors and residents currently tested for COVID-19?
- 05Who is responsible for infection prevention and control now, and how are outbreaks prevented or managed?
This was a targeted inspection of infection prevention and control, visiting arrangements and staffing pressures; it did not provide a full quality rating. This explanation was written from the published report of 26 February 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, November 2019
Rated Good overall, but inspectors said leadership and quality monitoring still required improvement and that recent improvements were not yet fully embedded.
Inspectors visited unannounced on 10 October 2019 and returned on 15 October 2019. They spoke with people living in the home, relatives, staff and a health care professional. They reviewed care records, medicines records, staff files and management information.
The home was rated Good for being safe, effective, caring and responsive. Inspectors found detailed risk assessments, safe medicines management, enough staff, kind care, personalised records and activities for people. They also found improvements in staff supervision, consent processes and risk management.
Well-led was rated Requires Improvement. The provider had improved after the previous inspection, but inspectors could not yet be sure that the improvements would be maintained consistently. Some care records contained inconsistencies, and the quality of governance systems was still developing.
The overall rating was Good, which means the inspectors found the care to be good in most areas. The previous overall rating was Requires Improvement, and the provider was no longer in breach of the regulations identified at earlier inspections.
Detailed risk planning
Risk assessments were person-centred and reflected people's current needs. They also explained how specialist equipment should be used.
“Care records included a range of risk assessments. These were person centred, detailed and reflective of people's current care and support needs.” from the report
Safe medicines
Medicines were given by trained and assessed staff. Storage, stock checks and information about creams and as-required medicines supported safe administration.
“Medicines were only administered by staff who had received training and had been assessed as competent.” from the report
Kind and respectful care
Inspectors observed friendly, professional interactions. Staff respected privacy and dignity and encouraged people to do things for themselves.
“Staff were kind, caring and professional. People were treated with dignity and respect.” from the report
Personalised activities
The activities co-ordinator planned activities around people's preferences and arranged activities on both inspection days.
“The activities co-ordinator told us they planned activities based on people's likes and dislikes.” from the report
Improvements since the last inspection
The provider had acted on earlier concerns about risk management, staff supervision and consent. The home was no longer in breach of the regulations identified at previous inspections.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 12.” from the report
Care record inconsistencies
needs fixingMost care records were detailed and person-centred, but some information did not match consistently. This was discussed with the manager.
“We noted some minor inconsistencies in people's care records. We discussed this with the registered manager at the time of the inspection.” from the report
Quality systems still developing
needs fixingThe home had audits and an action plan, but inspectors said future visits would need to check whether governance systems became consistently reliable.
“Future inspection will seek to evidence a sustained and consistent high level of quality has been achieved and that systems of governance are reflective, transparent and robust.” from the report
Some monitoring was not fully consistent
minorCare plans said some people should be weighed weekly, but this did not always happen as planned.
“People were weighed regularly although were care plans noted people were to be weighed weekly, this was had not always strictly adhered to.” from the report
- 01What checks do you now use to make sure care records are consistent and up to date?
- 02How have you shown that the improvements found in 2019 have been sustained?
- 03How often are people weighed when their care plan says weekly, and what happens if a planned check is missed?
- 04What quality audits and management checks are currently in place, and how are actions followed through?
- 05How are capacity assessments and best-interest decisions checked for consistency and detail?
This was a planned inspection covering all five CQC questions, after the home's previous Requires Improvement rating. This explanation was written from the published report of 14 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 Hartshead Manor
6 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- November 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2019Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Inadequate
- September 2018Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- July 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2016Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 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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