CQC report explained · a residential care home
What the CQC found at Hope Green Residential 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, January 2022
Rated Requires Improvement; inspectors found better records and safer recruitment, but concerns remained about cleanliness, medicines creams and management consistency.
This was an unannounced focused inspection on 17 and 21 December 2021. Inspectors looked only at Safe and Well-led, including infection control. They spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and management records.
The home had improved since the previous inspection. Care plans and risk assessments were person-centred, most medicines were managed safely, and checks on staff suitability had improved. However, records for some prescribed creams were incomplete, some areas were not consistently clean, and the home still relied on agency staff.
Management had changed several times. A new manager had been appointed but was not yet registered. Some relatives did not feel well informed or confident that their concerns were listened to. The overall rating remains Requires Improvement, as it was at the previous inspection and for the last two consecutive inspections.
Safer medicines practice
Apart from shortfalls in recording creams, inspectors found that medicines were managed safely and given by trained staff.
“All other aspects of medication were managed safely. Medicines were only administered by staff who were suitably trained.” from the report
Recruitment checks
The home had appropriate checks for permanent and agency staff, and agency workers received an induction.
“Detailed profiles were now obtained for all agency workers. Records demonstrated they received an induction when starting to work at the service.” from the report
Kind staff interactions
Inspectors saw staff treating people kindly, and staff knew the people they supported.
“People were treated in a caring manner by staff who knew them well.” from the report
Cream records
needs fixingSome prescribed creams were not consistently recorded, so the records did not always show clearly that they had been given as directed.
“We identified some shortfalls in the recording of creams, but overall records had improved.” from the report
Cleanliness
needs fixingSome areas were not always thoroughly cleaned. The shortage of ancillary staff affected the home's ability to maintain cleaning.
“A lack of ancillary staff had impacted on the ability for thorough cleaning in some areas to always be maintained.” from the report
Staffing and call bells
needs fixingThe home continued to rely on agency workers and had repeated shortages of ancillary staff. One person reported delays when using the call bell.
“However, one person told us of delays at times in staff responding to their call bell.” from the report
Management communication
needs fixingSeveral management changes meant some relatives did not feel well informed or confident that their concerns were being addressed. The home also had no registered manager at the time.
“This inconsistency meant some relatives didn't always feel the management team was responsive to any issues or concerns they had raised and didn't always feel well informed.” from the report
Personal choice
minorPeople in one part of the home did not have the option of taking a shower if that was their preference.
“People living in one part of the home still had no option to take a shower if this was their preference.” from the report
- 01How do you now check that prescribed creams are given and recorded correctly for each person?
- 02What has been done to keep all areas of the home clean when ancillary staff are unavailable?
- 03How are you reducing reliance on agency staff and preventing delays in responding to call bells?
- 04How will the new manager keep relatives informed and make sure complaints are listened to?
- 05When will the new manager complete registration with CQC?
This was a focused inspection of Safe and Well-led, including infection control; the other three key questions were not inspected and their previous ratings carried over. This explanation was written from the published report of 13 January 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, January 2021
Hope Green Residential Home is rated Requires Improvement; inspectors found caring staff and a clean home, but gaps in records, agency worker checks and personalised care created risks.
This was an unannounced focused inspection on 1 and 7 December 2020. Inspectors spoke with people, relatives and staff, observed care, and reviewed care records, medicines records, staff files and management records. They looked only at Safe, Responsive and Well-led.
The home was not always safe or responsive. Checks on temporary agency workers were missing or incomplete. Records about creams, weights, hydration and personal care had gaps. Some people waited a significant time for help after lunch, and care plans did not always reflect people's preferences, interests or contact with relatives.
Inspectors found the home was visibly clean and that regular staff had appropriate checks and training. People and relatives generally said they felt safe and well cared for. End of life care plans were sensitively written, and activities were provided.
The overall rating fell from Good to Requires Improvement. The home breached regulations about person-centred care, good governance, and fit and proper staff. Inspectors asked for an action plan and said they would monitor progress and return to inspect.
Clean environment
Despite pressure on domestic staff during the pandemic, inspectors found the home clean and well maintained.
“the home was visibly clean and well maintained.” from the report
Staff training
Regular staff had appropriate employment checks, and staff had completed the necessary training, including safeguarding training.
“Staff had received all necessary training.” from the report
Activities and relationships
Staff knew some people's likes and dislikes. Inspectors saw positive relationships and activities such as making Christmas cards.
“We also observed genuine friendships had been formed between people living at Hope Green.” from the report
End of life care
End of life care plans showed involvement in decisions, and relevant resuscitation information was clearly recorded.
“these plans were sensitively written, demonstrating people had been involved in decision making.” from the report
Agency worker checks
seriousChecks on temporary workers were absent or incomplete. Inspectors said this placed people at risk because suitability and experience had not been properly assessed.
“We found these checks were absent or incomplete.” from the report
Incomplete care records
seriousRecords for prescribed creams, weights, hydration and personal care were incomplete. This meant the home could not show that some health and personal care needs were being monitored safely.
“A number of people had significant gaps in records where they required support to ensure adequate hydration.” from the report
Personalised care and choice
seriousCare plans were generic and did not always record new residents' interests, emotional support needs or contact with relatives. Some people had access only to a bath when they preferred a shower.
“This meant new residents who were isolating in line with government guidance during the Covid-19 pandemic did not have their interests or emotional support needs identified.” from the report
Delays after meals
needs fixingInspectors saw people who needed physical help waiting a significant time after lunch to be supported to their chosen area. They recommended reviewing how staff were deployed at mealtimes.
“We observed a number of people requiring physical assistance waiting a significant time after their lunchtime meal to be assisted to their area of choice.” from the report
Weak quality monitoring
seriousAudits and checks did not consistently identify shortfalls or show that actions had been completed. This included monitoring hydration, weight and personal care.
“Care plan audits did not evidence how actions had been followed through.” from the report
Incidents not notified
seriousThe home had not notified the CQC about a number of incidents. Inspectors identified this as a potential breach and said they would follow it up separately.
“the registered manager and the registered provider had failed to notify the CQC of a number of incidents which had occurred at the home.” from the report
- 01What checks are now completed before temporary agency workers start work, and how do you confirm their training and experience?
- 02How do you now record and check people's hydration, weights, prescribed creams and personal care?
- 03How are care plans made personal to each resident, including their interests, emotional needs, bathing preference and contact with family?
- 04What has changed in staff deployment after meals so that people who need physical help are not left waiting?
- 05How do you make sure all incidents that must be reported to the CQC are notified promptly?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 21 January 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 Hope Green Residential Home
4 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- January 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- February 2019Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Good
- August 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 11 November 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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