CQC report explained · a nursing home
What the CQC found at Immacolata House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about infection prevention and control, including PPE, testing, hygiene, visiting and outbreak planning. They signposted the provider to resources about staff disposing of PPE when entering the home.
- Effective?
- Good
- Not assessed in this targeted inspection.
- Caring?
- Good
- Not assessed in this targeted inspection.
- Responsive?
- Good
- Not assessed in this targeted inspection.
- Well-led?
- Good
- Not assessed in this targeted inspection.
What inspectors found, April 2021
Inspected but not rated; inspectors found good infection control, with a minor issue about disposing of staff PPE.
This was an announced, targeted inspection on 17 March 2021. It focused on infection prevention and control during the COVID-19 pandemic.
Inspectors found that staff had enough PPE, including masks, gloves and aprons. Staff understood how to use it, infection control audits were completed, and regular COVID testing was carried out.
The home supported visiting safely through booking arrangements, protective equipment and video calls. Inspectors were assured about the main infection control arrangements, but the service was not given a quality rating.
PPE and infection control
Staff had additional training and used PPE properly. The home had supplies and infection control stations around the building.
“There were sufficient stocks available including masks, gloves, aprons and hand sanitiser.” from the report
Monitoring and oversight
The home completed infection control audits and used action plans to follow up any required work.
“Infection prevention and control audits took place and action plans were developed to follow up on any required actions.” from the report
Safe contact with relatives
The home used booked visiting times, protective equipment and video calls to support contact while reducing infection risks.
“A booking system was in place to support visitors at a time that suited people and was spaced out to avoid potential infection transmission with other visitors.” from the report
Testing and outbreak planning
Regular COVID testing was carried out for staff and residents. Plans were in place for a COVID-19 or other emergency outbreak.
“Regular COVID testing was carried out at the service for both staff and people living there, and contingency plans in were in place in the event of any outbreak of Covid-19 or other emergency.” from the report
PPE disposal
minorInspectors signposted the provider to resources to improve how staff disposed of PPE when entering the home.
“We have also signposted the provider to resources to develop their approach, in regards staff disposing of their PPE on entering the service.” from the report
- 01How do staff now dispose of PPE when entering the home?
- 02How often are staff and residents tested, and what happens if there is a positive result?
- 03How can relatives visit, and what protective equipment or booking arrangements are currently required?
- 04What is the current plan if there is an outbreak of COVID-19 or another emergency?
- 05What infection control audits have been completed since this inspection, and what actions followed?
This was a targeted inspection of infection prevention and control during the COVID-19 pandemic; the service was inspected but not rated and the wider areas of care were not assessed. This explanation was written from the published report of 13 April 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, January 2019
Immacolata House was rated Good; inspectors found safe, kind and personalised care across all five areas.
The inspection was unannounced on 20 November 2018 and announced on 21 November 2018. Inspectors spoke with people living at the home, staff, relatives and a healthcare professional. They observed care and checked care plans, staff records, training and other records.
The home supported 49 people, mainly people living with dementia, and could accommodate up to 49 people. Inspectors found suitable arrangements to protect people from abuse, manage risks, give medicines safely and keep the environment safe.
Staff were described as skilled, kind and respectful. Care was personalised, relatives were involved, and people were offered activities, healthcare support and choices about their daily lives.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. This was the same overall rating as at the previous inspection, so the report was written in a shorter format.
Safe recruitment and safeguarding
The provider checked new staff before they started and staff understood how to recognise and report abuse.
“Before commencing work all new staff were thoroughly checked to make sure they were suitable to work with vulnerable people.” from the report
Kind and respectful care
Inspectors saw staff treating people with patience and kindness. Staff protected privacy and supported people's independence.
“Throughout the inspection we observed staff spoke to people respectfully and showed kindness and patience when supporting them.” from the report
Personalised support
Care plans recorded people's preferences and life histories. Staff used this information to provide meaningful support and conversation.
“Care plans were person centred and included people's likes dislikes and a life history.” from the report
Meaningful activities
People could choose from activities in the home and community, including walks, trips, visits and involvement with the small holding.
“People took part in a range of meaningful activities which included in-house entertainment, trips out and walks in the grounds” from the report
Active quality monitoring
Managers carried out regular checks and acted when they found shortfalls. Changes included improving hydration support and mealtime assistance.
“We saw that where shortfalls in the service had been identified action had been taken to improve practice.” from the report
Occasional call bell waits
minorSome people and relatives said there were occasional waits for call bells. Inspectors found that call bells were answered promptly during the inspection.
“Although some said there were occasional waits. During the inspection all call bells were promptly answered.” from the report
- 01Some people reported occasional waits for call bells. How do you monitor response times, and what happens when there is a delay?
- 02How will you make sure care plans continue to reflect each person's likes, dislikes, life history and communication needs?
- 03How are relatives involved when a person cannot make a decision about their care?
- 04What activities are currently available for people who prefer to stay in the home rather than go out?
- 05How do your audits check medicines, hydration, nutrition and repositioning records, and how do you act on any shortfalls?
This was an overall inspection covering all five CQC questions, including the premises and the care provided; the previous overall rating was also Good. This explanation was written from the published report of 23 January 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 Immacolata House
2 rated inspections over 2 years: the service has held its Good rating throughout.
- April 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- January 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 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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