CQC report explained · a residential care home
What the CQC found at Hepscott Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe medicines processes, suitable safeguarding arrangements and regularly reviewed risk assessments. Infection control systems were in place, although some parts of the building showed wear and tear.
- Effective?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Good
- Inspectors found effective quality checks, clear oversight and a positive, person-centred culture. Staff and relatives said communication was effective and managers were approachable.
What inspectors found, December 2022
Rated Good; inspectors found safe, caring support and effective management, with some wear and tear needing refurbishment.
This was an unannounced focused inspection. Inspectors visited on 22 November 2022 and carried out inspection activity until 28 November. They spoke with people, relatives, staff and a visiting healthcare professional, and observed care.
The inspection looked only at Safe and Well-led. Both areas were rated Good. Inspectors found enough staff, safer medicines systems, appropriate risk assessments and good safeguarding arrangements. People and relatives described staff as kind, dedicated and trustworthy.
The home had improved since the previous inspection, which was rated Requires Improvement in July 2021. The earlier breach about medicines was no longer in place. The overall rating became Good, but some ratings from the previous inspection were carried forward because they were not examined this time.
Safe staffing
Inspectors found enough staff to support people safely and promptly. Staff were recruited with the required checks.
“There were sufficient staff to support people safely.” from the report
Improved medicines safety
The home had improved its systems for prescribing, giving, recording and storing medicines. The previous breach relating to medicines was no longer in place.
“Staff followed systems and processes to prescribe, administer, record and store medicines safely.” from the report
Kind and trusted staff
People and relatives spoke positively about staff. Inspectors found good relationships and support that was discreet, compassionate and person-centred.
“People and relatives were very positive about the caring nature of staff and had good relationships with them.” from the report
Effective management checks
Managers used audits and acted when they found areas needing improvement. They also checked that changes from the previous inspection had been made.
“Management made regular checks on the quality of the service using a range of audits.” from the report
Wear and tear
minorSome parts of the home were not well maintained. Marked carpets needed replacement, and the provider supplied an action plan for refurbishment.
“Some carpets were marked and showing signs of wear and tear.” from the report
- 01What work has been completed from the refurbishment action plan, and when will any remaining marked carpets be replaced?
- 02How do you check that medicines continue to be prescribed, given, recorded and stored safely?
- 03How many staff are usually on duty for the number and needs of residents, and how often are agency staff used?
- 04How will you keep relatives informed when a person's care or health needs change?
- 05What were the previous ratings for Effective, Caring and Responsive, and when will these areas next be inspected?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection and were used to calculate the overall Good rating. This explanation was written from the published report of 3 December 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, July 2021
Rated Requires Improvement; inspectors found personalised care and better infection control, but medicines safety and oversight still needed improvement.
This was a follow-up inspection after the previous Requires Improvement rating. One inspector visited on 14 June 2021, observed care, spoke with five staff members and checked care, medicines, recruitment and management records.
The home had improved its infection control. Staff used protective equipment correctly, the home was clean and tidy, and people had enough staff to meet their care needs. People received personalised care, activities were available and relatives could visit safely.
There was a serious shortfall in the management of controlled medicines. Records were inaccurate, storage was not always safe and there was no regular checking system. The home was also still not well-led enough because its safety monitoring did not identify this problem.
The overall rating remained Requires Improvement. Safe and well-led were rated Requires Improvement, while responsive improved to Good. The provider was no longer in breach of the earlier regulations, but a new breach was found concerning medicines.
Improved infection control
Inspectors found effective infection control practices. Staff used protective equipment correctly and followed current government guidance.
“There were now effective infection control practices at the home.” from the report
Personalised care
Care records included people's choices and preferences, and inspectors found that care was tailored to people's needs.
“People received personalised care that met their needs.” from the report
Activities and visits
The home offered activities and supported regular, safe visits from relatives during the COVID-19 pandemic.
“The service followed good practice guidelines to ensure people had regular and safe visits from relatives, both within the home and in a garden visiting pod.” from the report
Staffing and recruitment
Although there was a shortfall in staffing numbers and some agency staff were used, inspectors found enough staff to meet people's care needs. Recruitment checks were completed safely.
“There were enough staff to provide for people's care needs.” from the report
Controlled medicines
seriousRecords for controlled medicines were inaccurate and storage was not always safe. There was no regular checking system, creating a potential risk that people might not receive medicines correctly.
“Records relating to controlled medicines were not accurate and storage of controlled medicines was not always safe.” from the report
Weak safety oversight
needs fixingQuality monitoring had improved, but it did not include an effective check on controlled medicines. This meant management systems had not identified or prevented the medicines problem.
“There was no effective system to monitor the safety of controlled medicines in the home.” from the report
Care review involvement
minorThere was only some evidence that people had been involved in regular care reviews. The acting manager was asked to find ways to increase this involvement.
“There was some evidence people had been involved in periodic reviews of care.” from the report
- 01What changes have you made to the storage and recording of controlled medicines since this inspection?
- 02How often are controlled medicines now checked, who completes the checks and how are the results recorded?
- 03What evidence can you show that the medicines breach has been fully resolved?
- 04How are people and their representatives now involved in periodic care reviews?
- 05How are you ensuring there are enough staff across all parts of the service, including domestic and activities work?
This was a follow-up inspection of the previous concerns, including infection control, and the report rated Safe, Responsive and Well-led; it did not give ratings for Effective or Caring. This explanation was written from the published report of 29 July 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 Hepscott Care Centre
6 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- December 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2021Requires improvementdown from GoodSafe: Requires improvementResponsive: Inspected but not ratedWell-led: Requires improvement
- May 2018Goodup from Requires improvementSafe: GoodResponsive: Requires improvementWell-led: Good
- January 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- October 2010
Registered with the Care Quality Commission on 1 October 2010.
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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