CQC report explained · a nursing home
What the CQC found at Haven Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2022
Rated Good overall; Haven Nursing Home was well-led, but inspectors found safety and infection-control improvements were needed.
This was a targeted responsive inspection after a COVID-19 outbreak. Inspectors visited on 25 January and 9 February 2022. They spoke with people, relatives and staff, and checked care, medicines, recruitment and management records.
The home had enough staff, medicines were generally managed safely, and staff understood how to protect people from abuse. However, cleanliness and infection-control arrangements were not always effective. Inspectors found dust, worn paintwork, toilets that were not always cleaned effectively and a trip hazard caused by unfinished flooring work.
The home acted during the inspection. The trip hazard was removed, some woodwork was replaced or repainted, and extra checks were introduced for mattresses, medicines and visitors. The overall rating remained Good, but Safe fell from Good to Requires Improvement. Well-led remained Good.
Enough staff
Inspectors found enough care and nursing staff to meet people's needs. Staff and relatives also said staffing levels were safe.
“There were enough care and nursing staff to care for people safely.” from the report
Safeguarding
Staff knew how to recognise and report abuse, and people were protected from the risk of abuse.
“People were protected against the risk of abuse. Procedures were in place to report safeguarding incidents to the local authority safeguarding team and CQC.” from the report
Management and feedback
The management team worked together, welcomed feedback and used audits and action plans to make improvements.
“The provider was committed to making improvements at Haven Nursing Home. Feedback from our inspection was welcomed and assurance was provided that action would be taken” from the report
Communication with relatives
Relatives were regularly updated about their family members, particularly during the COVID-19 outbreak.
“Relatives told us they were rung regularly and provided with an update about how their family members were, especially during the most recent outbreak of COVID-19.” from the report
Cleanliness and infection control
seriousOn the first inspection day, some areas were dusty, paintwork was worn and one toilet was not cleaned effectively. Building work and the COVID-19 outbreak had made cleaning more difficult.
“On the first day of our inspection visit we found the cleanliness of the home needed to be improved.” from the report
Trip hazard from unfinished work
seriousA partial removal of flooring and carpet created a trip hazard in a corridor used by staff and residents. It was removed before the second inspection day.
“On the first day of our inspection visit we found there was a trip hazard near a doorway to a cleaning room” from the report
Medicine records and checks
needs fixingSome fridge-stored medicines did not have opening dates recorded. Some medicine patches were not recorded as being moved to a new body site, and some as-required medicines lacked clear protocols.
“However, some people did not have a clear plan in place.” from the report
Visitor vaccination checks
needs fixingTwo health professionals entered without their vaccination status being checked first. The home corrected this during the visit and monitored later checks.
“However, on the second day of our inspection visit two health professionals entered the home without a check of their vaccination status taking place.” from the report
- 01What cleaning, repainting and woodwork work has now been completed, and how do you check that areas remain clean?
- 02How are unfinished building works kept safe so they cannot create trip hazards?
- 03How do you check every mattress setting after a mattress has been moved or cleaned?
- 04How do you make sure fridge-stored medicines have opening dates and that as-required medicines have clear protocols?
- 05How do you check vaccination status for every staff member and professional visitor before they enter?
This was a targeted responsive inspection of Safe and Well-led, prompted by a COVID-19 outbreak; the report gives no new ratings for Effective, Caring or Responsive. This explanation was written from the published report of 18 March 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, August 2019
Haven Nursing Home was rated Good in all five areas; inspectors found kind, responsive care, with some care records needing improvement.
This was an unannounced inspection on 3 July 2019. Inspectors spoke with people living in the home, relatives, staff and health professionals. They observed care and reviewed care, medicine, complaints and management records.
The home was rated Good for Safe, Effective, Caring, Responsive and Well-led care. Inspectors found people were treated kindly, involved in decisions, supported by trained staff and given opportunities for activities and rehabilitation.
The home had improved from Requires Improvement at the previous comprehensive inspection. A new provider and management team had introduced changes, including stronger audits, staff training and regular feedback from people and relatives.
Inspectors still found that some risk information was split between nursing and care records. This could make it harder for care staff to see all the information needed to manage risks consistently.
Kind and respectful care
People and relatives described the care as very good. Staff supported privacy, dignity, communication and personal choices.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Staff training
The home had introduced a new training plan, with induction, refresher training and specialist development for staff.
“The new provider had introduced a new training plan for staff, ensuring induction procedures and ongoing training provided staff with the right skills and competencies.” from the report
Activities and social contact
People were offered group and individual activities based on their interests. Staff also spent time talking with people and helping them stay connected.
“There were activities co-ordinators employed by the provider seven days per week, to ensure people were offered some activities each day.” from the report
Improving management
The new provider and management team had introduced audits, action plans and regular opportunities for people, relatives and staff to give feedback.
“The audits and action plan helped the provider to monitor and improve care for the people using the service.” from the report
Risk information was split
needs fixingRisk plans were kept separately in nursing and care records. This meant care staff might not always see all the information needed to manage risks consistently, although inspectors found staff knew people well and managed risks safely.
“This meant information about risks was not always reflected in the care plans used by care staff to ensure there was a consistent approach to managing risks.” from the report
Data protection allegation
minorAfter the inspection, the home told inspectors about an allegation that personal information had been shared. The provider was investigating this through its complaints process.
“Following our inspection visit we were made aware of an allegation that the provider had breached data protection guidance by sharing someone’s personal information.” from the report
- 01Have the nursing and care records now been combined so every care worker can see the latest risk information?
- 02What changes were made after inspectors found that risk information was split between different records?
- 03What was the outcome of the investigation into the alleged sharing of personal information?
- 04How are people and relatives involved in reviews of care plans and decisions about daily care?
- 05How do you check that staff training and medicine administration skills remain up to date?
This was an unannounced comprehensive inspection covering all five key questions, including both the care provided and the home premises. This explanation was written from the published report of 8 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 Haven Nursing Home
8 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- March 2022Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- July 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2016Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2015Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- May 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 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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