CQC report explained · a nursing home
What the CQC found at Lace Hill Manor Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Medicines, infection control, environmental checks and staffing were generally managed safely, although recruitment records and fire drill records needed improvement.
- Effective?
- Good
- People received suitable food and timely support from health professionals. Staff training and supervision records had gaps, and the environment could have been better adapted for people with dementia.
- Caring?
- Good
- Staff were described and observed as kind, respectful and compassionate. People were involved in decisions and supported to maintain dignity and independence.
- Responsive?
- Requires improvement
- Activities, communication support, visiting and end of life planning were positive. However, care plans were sometimes incomplete, confusing or inaccurate, and some relatives were unclear about how to raise concerns.
- Well-led?
- Requires improvement
- People and staff gave positive feedback about the manager and were involved through meetings. However, records and quality checks did not reliably identify or address shortfalls, leading to a breach of Regulation 17.
What inspectors found, June 2023
Lace Hill Manor Care Home was rated Requires Improvement; inspectors found safe, kind care but weaknesses in care records and quality checks.
This was a planned inspection of a newly registered care home. Inspectors visited on four dates, spoke with people, relatives and staff, observed care and activities, and checked care plans, medicines, recruitment files, training records and audits.
The home was rated Good for Safe, Effective and Caring. Inspectors found enough staff, safe medicines practice, good infection control, kind and respectful care, suitable food and good links with health professionals.
The home was rated Requires Improvement for Responsive and Well-led. Care plans were not always up to date or easy to follow. Records did not consistently show that people received fluids or repositioning at the required times. Audits had not identified several of these problems.
The provider breached Regulation 17 on good governance. CQC required an action plan and said it would monitor progress with the provider and local authority.
Safe staffing and medicines
There were enough staff to meet people's needs. Staff handled medicines safely and supported people patiently, including when medicines had to be given at particular times.
“People were supported by staff who had received training on how to support them safely with their medicines.” from the report
Kind and respectful care
Inspectors saw kind and compassionate interactions. People were supported with privacy, dignity and independence, and were involved in decisions about their care.
“We observed interactions between people and staff were kind, caring and compassionate.” from the report
Food and mealtimes
People gave positive feedback about the food. Staff offered alternatives and supported people to eat in a patient and dignified way.
“We observed people were supported in a dignified, patient manner and given time to enjoy their meal.” from the report
Activities and visiting
People had access to varied activities and relatives said they could visit freely. Inspectors saw people enjoying music, drinks and cake together.
“This activity was really enjoyed by people. There were lots of smiles, toe tapping and some dancing, supported by staff where necessary.” from the report
Care records were unclear
needs fixingCare plans did not always give a clear or accurate picture of people's needs. Multiple records made it difficult to see what care had been provided.
“Care plan records were quite difficult to follow, to establish the support a person had received in any 24 hour period.” from the report
Daily care was not consistently recorded
seriousRecords of fluid intake and repositioning did not always show that support had happened at the required intervals. Staff could not always confirm whether the required care had been provided.
“They were unable to ascertain if people had received the care they required.” from the report
Quality checks missed problems
seriousThe home's audits did not identify important shortfalls in records and safety equipment. This led to a breach of Regulation 17.
“This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as the provider had failed to effectively assess, monitor and improve the quality and safety of the service.” from the report
Some staff records and training needed improvement
needs fixingSome recruitment files lacked proof of identity and a recent photograph. Some staff worked before completing required training, although training was updated during the inspection.
“Some staff were working with people without having completed the required training.” from the report
- 01How have you simplified and updated care plans so they accurately show each person's needs and daily care?
- 02How do you now check and record fluid intake and repositioning at the required intervals?
- 03What action has been completed in response to the Regulation 17 breach, and can you explain how your audits now identify problems?
- 04Have all staff completed the required training, including food safety training where relevant?
- 05What changes have been made to fire drills and to the environment for people living with dementia?
This was the first planned inspection of the newly registered home and covered all five CQC questions, including infection prevention and control. This explanation was written from the published report of 21 June 2023 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 Lace Hill Manor Care Home
Each visit the CQC has published, newest first, back to the day the home was registered.
- June 2023Requires improvementcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2022
Registered with the Care Quality Commission on 6 April 2022.
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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89 live-in carers within about an hour of Buckinghamshire
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 £1,300 a week. 79 can care for a couple. 13 years' experience on average.
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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.