CQC report explained · a nursing home
What the CQC found at Havencroft Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- The home had good arrangements for visitors, distancing, cleaning, testing, safe admissions and managing infection risks. Inspectors were not fully assured about some PPE use and the infection control policy, but both issues were addressed immediately.
- Effective?
- Good
- This question was not assessed in this targeted inspection.
- Caring?
- Good
- This question was not assessed in this targeted inspection.
- Responsive?
- Good
- This question was not assessed in this targeted inspection.
- Well-led?
- Good
- This question was not assessed in this targeted inspection.
What inspectors found, March 2021
Inspected but not rated; inspectors found strong infection control arrangements, but PPE use and the infection policy needed improvement.
This was an announced, targeted inspection on 28 January 2021. It looked only at infection prevention and control during the coronavirus pandemic, rather than the full quality of care.
Inspectors found good arrangements for visitors, social distancing, cleaning, testing, safe admissions and keeping people in contact with their families. The home used a visitor pod, screened visitors and organised video and telephone calls.
Inspectors were not fully assured that some staff were using the right PPE or that the infection control policy was up to date. The home addressed both points immediately after they were raised. The service was inspected but not rated, so this report does not give an overall quality rating.
Safer family visits
Visitors were screened, given PPE and kept away from the main route through the home. A visitor pod allowed families to meet safely by appointment.
“The provider had installed a visitor pod for families to safely visit people.” from the report
Reducing infection spread
Staff were grouped and assigned to particular floors to reduce movement. Cleaning was carried out more often, including attention to touchpoints and bedrooms.
“The provider cohorted staff in pairs and zoned staff to work on a specific floor to minimise staff movement in the home and reduce the risk of spreading infection.” from the report
Keeping families connected
Staff supported regular video and telephone calls with families. Activities were arranged in a large room so people could keep apart.
“To ensure people's wellbeing was promoted the activities co-ordinator and staff organised and supported regular video and telephone calls with families to ensure everyone maintained contact.” from the report
Safe admissions
Admission assessments were completed by video call, with families offered a video tour and pictures of the home.
“Admission assessments were carried out by using video calls.” from the report
PPE was not always appropriate
needs fixingInspectors saw some staff wearing their own masks rather than the appropriate masks under current guidance. The home addressed this immediately.
“We were not fully assured that the provider was using PPE effectively and safely.” from the report
Policy was out of date
needs fixingThe infection prevention and control policy did not reflect current government guidance and had not been updated since March 2020. It was updated after the inspection.
“The providers policy did not reflect current government guidance and had not been updated since March 2020.” from the report
- 01How do you check that staff are using the correct PPE now?
- 02When was the infection prevention and control policy last reviewed, and how do you keep it aligned with current guidance?
- 03How are visitor pod appointments arranged, and how is the pod cleaned between visits?
- 04How do you reduce staff movement between floors and communal areas?
- 05How are new admissions assessed safely, and what information is shared with families before admission?
This was a targeted inspection of infection prevention and control under the Safe question only; the service was inspected but not rated and the other questions were not assessed. This explanation was written from the published report of 2 March 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.
What inspectors found, September 2019
Rated Good; inspectors found safe, kind and personalised care, but some records and management arrangements needed attention.
This was an unannounced planned inspection. Inspectors spoke with people, relatives, staff and a visiting professional. They observed care and reviewed care plans, medicines records, staff files, training, accidents and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe care, kind relationships and support that reflected people's needs, choices and communication methods.
There were some issues to address. One medicines fridge did not lock easily, some equipment needed more cleaning, some care plans lacked detail or were incomplete, and there was no registered manager in post. The provider was recruiting one.
The home was also rated Good at the previous inspection, published on 17 February 2017. This inspection found that all five ratings remained Good.
Enough staff
Inspectors found there were enough staff to meet people's care needs. Recruitment checks were completed before staff started work.
“People were supported by enough staff to meet their care needs.” from the report
Kind and respectful care
People and relatives spoke positively about the staff. Inspectors observed caring interactions and found that dignity and privacy were respected.
“Staff were caring in their approach and had good relationships with people and relatives.” from the report
Personalised support
Staff knew people well and care records included information about their backgrounds, interests, likes and dislikes. Communication was adapted for people's needs.
“Care records were person centred and contained information which enabled staff to understand about their likes, dislikes and preferences.” from the report
Good food and health support
People were supported with meals suited to their needs, including softened diets and low-sugar choices. Staff worked with health professionals to support people's wellbeing.
“Specific dietary needs were catered for and risks managed.” from the report
Medicines fridge
needs fixingOne fridge used for medicines did not lock easily. The business manager said this would be addressed.
“We noted one fridge containing medicines did not lock easily and the business manager confirmed this would be addressed.” from the report
Incomplete care records
needs fixingSome care plans had become less detailed in recent months, and some had not been completed. Inspectors discussed the need for stronger clinical oversight.
“It was noted these contained less detail in recent months and in some instances had not been completed.” from the report
No registered manager
needs fixingThere was no registered manager during the inspection. The provider was recruiting someone for the role, and staff said they wanted a manager to oversee clinical matters.
“There was no registered manager in post. The provider was in the process of recruiting a registered manager.” from the report
Privacy of displayed information
minorSome personal information could be seen by visitors. The business manager said it would be moved to keep it confidential.
“During our visit we noted some personal information displayed could be visible to visitors to the service.” from the report
- 01Has a registered manager now been appointed, and who oversees clinical care in the meantime?
- 02What action was taken to make sure the medicines fridge locks securely?
- 03How do you check that all care plans are complete and updated when people's needs change?
- 04What was done about the equipment that inspectors said needed further cleaning?
- 05What changes have been made to provide more variety in food and activities?
This was an unannounced planned inspection covering all five CQC questions, including the premises and care provided. This explanation was written from the published report of 10 September 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 Havencroft Nursing Home
4 rated inspections over 5 years: the service has held its Good rating throughout.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- September 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015Goodstayed GoodEffective: Requires improvement
- January 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 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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