CQC report explained · a nursing home
What the CQC found at Highcroft Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found good infection-control arrangements, safe medicines management, safeguarding training, regular safety checks and enough staff to keep people safe.
- Effective?
- Good
- This area was not assessed during this focused inspection. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This area was not assessed during this focused inspection. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This area was not assessed during this focused inspection. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found an open, supportive culture, good communication with relatives, clear management responsibilities and regular checks on quality and safety.
What inspectors found, May 2021
Highcroft Nursing Home: Rated Good; inspectors found safe, kind care and improvements after an earlier infection-control breach.
This was an unannounced focused inspection on 28 April 2021. One inspector spoke with managers, staff, some residents and six relatives. They also checked care records, policies, audits and safety systems.
The home was rated Good for Safe and Well-led. Inspectors found that infection-control arrangements had improved, medicines were managed safely, and there were enough staff to keep people safe. People and relatives said they felt safe and were happy with the care.
The last inspection had found a breach about infection prevention and control. The home had completed an action plan, and this inspection found the required improvements had been made. The overall rating remained Good, but this inspection did not assess all five areas of care.
Infection control improved
The home had acted on the previous inspection findings. Inspectors found safe visiting, isolation, PPE, testing, cleaning and outbreak arrangements.
“At this inspection, we found required improvements had been made and there was no longer a breach of this regulation.” from the report
Safe medicines management
People had individual plans for medicines given when needed. Medicines were reviewed, stored and audited safely.
“At this inspection, each person had an individual PRN plan in the medicines records and their individual care record.” from the report
People felt safe
People and relatives said they felt safe. Staff had safeguarding training and knew how to report concerns.
“People's relatives told us they felt their family members were very safe at Highcroft Nursing Home.” from the report
Supportive leadership
Staff, people and relatives described a positive culture. Managers were seen as supportive, organised and approachable.
“The management team understood their responsibilities, and the service was organised and well run.” from the report
Previous infection-control breach
needs fixingThe previous inspection found that infection-control procedures did not always protect people from infection. This inspection found the improvements had been made, so the home was no longer in breach.
“At our last inspection, we found that infection control procedures did not always protect people from the risk of the spread of infection.” from the report
Staffing during the coronavirus outbreak
minorThe home had difficulty covering some shifts when staff were sick or isolating during a recent outbreak. Agency staff were used to maintain safety.
“During the recent coronavirus outbreak at the service, it had been difficult to cover some shifts when staff were off sick or isolating.” from the report
- 01What checks are now used to make sure infection-control arrangements remain effective?
- 02How do you cover shifts when staff are sick or isolating, and how often do you use agency staff?
- 03How are medicines given when needed reviewed and updated for each resident?
- 04How will you keep relatives informed about changes in a resident's health or care?
- 05What were the latest ratings for Effective, Caring and Responsive at the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 19 May 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, March 2021
Rated Good overall; inspectors found infection-control and some medicines-record problems, so Safe was Requires Improvement.
This was an inspection after concerns about infection control and a coronavirus outbreak. It began as a targeted inspection and was widened to look at Safe and Well-led. Inspectors visited on 25 and 27 November and 10 December 2020. They reviewed records, observed infection-control practice and spoke with relatives and staff.
The home was clean and there were enough staff to meet people's needs. Risks were assessed, medicines were stored safely and equipment checks were completed. Relatives and staff spoke positively about the care, communication and management.
Inspectors found that PPE, laundry arrangements and staff changing procedures did not always reduce the risk of infection. Some guidance and records for medicines given when needed also needed improvement. The home was rated Good overall, Safe fell from Good to Requires Improvement, and Well-led remained Good.
Clean environment
The home was clean and did not smell unpleasant. Relatives also confirmed that it was clean.
“The home was clean and free from malodours. Relatives confirmed the home was clean.” from the report
Staffing
Despite COVID-related absence, shifts were covered and inspectors found there were enough staff to meet people's needs.
“Although there had been some staff absence relating to COVID 19, the home remained safely staffed.” from the report
Positive leadership
Relatives and staff said managers were approachable and that teamwork and morale remained good during a difficult period.
“Staff told us although they had experienced a difficult time, morale and teamwork remained good.” from the report
Communication
Relatives reported regular contact and said information about COVID-19 had been shared with people and families.
“Communication has been very good, I have regular contact from them weekly, and I phone in every couple of days.” from the report
Infection-control practice
seriousStaff did not always wear or dispose of PPE correctly. Laundry and changing arrangements also increased the risk of spreading infection.
“Risks relating to infection control were not all being managed safely. We observed staff were not always wearing personal protective equipment (PPE) appropriately.” from the report
Isolation guidance
seriousOne person's care plan required 10 days of isolation when the guidance referred to 14 days. This was part of the breach of safe care and treatment requirements.
“One person's risk assessment who was recently admitted to the home stated they should be isolated in their room for 10 days, rather than the 14 days detailed in the government's guidance.” from the report
- 01What changes have been made to PPE use, disposal and staff changing since the inspection?
- 02How are laundry arrangements now managed to prevent cross-infection?
- 03How do you make sure isolation periods and other infection-control guidance are correct and followed?
- 04What has been done to add individualised guidance for medicines given when needed?
- 05How are handwritten medicines-record entries checked and double-signed now?
This was a focused inspection of Safe and Well-led after an infection-control concern; Effective, Caring and Responsive were not assessed and their ratings were not given in this report. This explanation was written from the published report of 20 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.
Every inspection of Highcroft Nursing Home
4 rated inspections over 4 years: the service has held its Good rating throughout.
- May 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2021Goodstayed GoodSafe: Requires improvementWell-led: Good
- August 2019Goodstayed GoodSafe: GoodWell-led: Good
- January 2017GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- February 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 18 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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