CQC report explained · a nursing home
What the CQC found at Horton Cross Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2024
Rated Inadequate and placed in special measures; inspectors found people were at risk because care, staffing and management systems were not reliable.
Inspectors visited the home without notice on 28 November and 1 December 2023. They spoke with people, relatives and staff, observed care, and checked care records, medicines, staffing, safety and management records.
They found people did not always receive safe care. Risks were not consistently managed, professional instructions were not always followed, and one person with existing pressure damage was left in the same position for seven hours. Staffing skills and supervision were also not always sufficient.
The home had improved medicine storage, recruitment checks and cleanliness. However, inspectors found repeated failures in safe care and management. The overall rating fell from Requires Improvement to Inadequate, and the home was placed in special measures.
Medicine safety
Inspectors found improvements in medicine storage and said people were supported to receive medicines safely. Nurses had training and competency checks, and medicines were stored securely.
“People were supported to receive their medicines safely.” from the report
Infection control
The home had improved its cleanliness. Inspectors were assured about infection prevention, the use of protective equipment and the management of infection risks.
“Improvements had been made to the overall cleanliness of the service.” from the report
Recruitment checks
Recruitment records showed that references and criminal record checks were being completed. This was an improvement since the previous inspection.
“Recruitment folders had a checklist, which demonstrated relevant checks were being undertaken to ensure new staff were recruited safely.” from the report
Fire and evacuation arrangements
Fire checks and drills were carried out, and people had emergency evacuation plans describing the help they would need.
“People had individual personal emergency evacuation plans (PEEPs) with information about their mobility and support needs should they need assistance to evacuate the building in an emergency.” from the report
Risk of pressure damage
seriousRepositioning plans were not consistently followed. One person with existing pressure damage was left in the same position for seven hours.
“We observed one person, with existing pressure damage, to be in the same position for 7 hours.” from the report
Unsafe care equipment
seriousStaff did not always use the equipment set out in care plans or professional guidance. This created risks when people were helped to drink or move.
“However, we observed staff assisting people with the wrong equipment. This put people at risk.” from the report
Insufficient skilled staffing
seriousOn the first inspection day, many care staff were from an agency and did not know people well. Call bells rang for more than 15 minutes on more than one occasion, and some people waited a long time for meals.
“On the first day of the inspection, we observed call bells ringing for over 15 minutes on more than one occasion.” from the report
Poor management oversight
seriousThe provider did not have effective systems to check care, staff work, records, incidents or improvement actions. This was a repeated breach of governance requirements.
“The provider did not have effective oversight of the care provided which meant they failed to comply with regulations, meaning people were at risk of harm.” from the report
Care not consistently personalised
needs fixingSeveral people stayed in bed or in their rooms for long periods, but records did not clearly show how these decisions had been made or how people's social needs were being met.
“Quality assurance processes had failed to address the fact there was a lack of stimulation and meaningful occupation for people being cared for in bed or choosing to stay in their room.” from the report
- 01How are you now checking that repositioning plans, wound care plans and professional instructions are followed on every shift?
- 02How many permanent nurses and care staff are currently working, and how are agency staff supervised when they do not know people well?
- 03What records and checks now show that call bells, meals and personal care are provided without unsafe delays?
- 04How do you record best-interest decisions for people who spend long periods in bed or in their rooms?
- 05What action has been taken in response to the Regulation 17 warning notice, and what evidence can you show of improvement?
This was a focused, unannounced inspection prompted by concerns, covering Safe and Well-led and infection prevention and control; the report does not give ratings for Effective, Caring or Responsive. This explanation was written from the published report of 13 January 2024 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, October 2022
Rated Requires Improvement; inspectors found kind care and good professional links, but identified safety, recruitment and management weaknesses.
This was an unannounced focused inspection on 17 and 24 August 2022. Inspectors spoke with people, relatives, staff and professionals, observed care, and checked care, medicine, recruitment, cleaning and management records.
The home was not always safe or well managed. Inspectors found gaps in risk information, environmental hazards, incomplete recruitment checks, some unclean areas and weaknesses in record keeping. Some medicine storage temperatures were not monitored, and there were gaps on medicine administration records.
There were also positive findings. People said they felt safe, staff were described as kind and supportive, and health professionals reported timely referrals and good communication. Staff had training and people were supported with decisions in line with their rights.
The overall rating fell from Good at the previous inspection, published in August 2018, to Requires Improvement. The report says the provider must send an action plan and that CQC will monitor progress.
People felt safe
People and relatives generally said they felt safe and had confidence in the staff. Inspectors saw people looking relaxed and comfortable with staff.
“People said they felt safe at Horton Cross Nursing Home mainly because they were confident in the care and support provided by staff.” from the report
Training and support
Staff had induction, core training and clinical training where needed. Staff said managers supported them and did not expect them to do tasks they could not do safely.
“Staff had been supported to develop the skills they needed to meet people's day to day needs.” from the report
Good professional links
Health and social care professionals reported timely referrals and good knowledge of people's needs. Weekly meetings were used to discuss people's health.
“People had access to external health and social care professional to ensure their health care needs were addressed.” from the report
Respect for decisions
Mental capacity assessments and best-interest decisions were in place where needed. Inspectors found support was provided in the least restrictive way.
“Support was provided to people in the least restrictive way possible.” from the report
Generally safe medicines practice
Medicines were generally ordered, stored and given safely. There were systems for higher-risk medicines, as-required medicines and medicines needed at specific times.
“People's medicines were generally managed safely.” from the report
Care and environmental risks
seriousCare records did not always explain important risks, including diabetes and swallowing needs. Inspectors also found hazards such as an exposed lift mechanism, a loose radiator, a ladder and unsafe water temperatures.
“Effective systems were not in place to minimise potential risks to people.” from the report
Weak quality checks
seriousThe provider's audits had not found several problems before the inspection. Care, blood glucose and repositioning records were incomplete or inaccurate, and cleaning checks were not properly recorded.
“Whilst actions to drive improvements were taken following our feedback, these concerns had not been identified by the provider's own quality assurance processes.” from the report
Cleanliness and infection control
needs fixingSome communal areas, the laundry sink and bathroom facilities were not clean. Some bedrail covers were damaged and harder to keep clean, although communal areas improved during the inspection.
“Some areas of the premises were not clean.” from the report
Limited bathing and activities
needs fixingOnly one assisted bathroom was available for 42 people, and relatives reported that some people had not had a bath for several weeks. Many people stayed in their rooms or beds with limited social activity.
“Some routines were not person centred.” from the report
Medicine temperature records
needs fixingStorage temperatures for medicines on the first floor were not monitored. Three medicine administration records also had signature gaps, so inspectors could not be sure all prescribed medicines had been given.
“This meant the medicines could be exposed to temperatures which affected their efficacy.” from the report
- 01What action has been completed to address the Regulation 12 breach and how are risks such as diabetes, swallowing, pressure injuries and environmental hazards now recorded and checked?
- 02Have all staff recruitment files been completed, including employment histories, previous conduct checks and DBS checks before staff start work?
- 03How are medicine storage temperatures now checked and recorded, and how are gaps on medicine administration records followed up?
- 04What has changed about access to bathing and showering, and how often can people receive baths in line with their preferences?
- 05How are daily routines, activities and time spent in bedrooms being reviewed so care is consistently person centred?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were used in the overall rating. This explanation was written from the published report of 20 October 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.
Every inspection of Horton Cross Nursing Home
4 rated inspections over 8 years: the service has slipped, from Good to Inadequate.
- January 2024Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Inadequate
- October 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- August 2018Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- May 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 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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76 live-in carers within about two hours of Somerset
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,370 a week. 62 can care for a couple. 12 years' experience on average.
“She looked after my mum, who can be incredibly challenging, so well and so gently, and we always felt confident that my mum was getting the best care available.”
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Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.