CQC report explained · a residential care home
What the CQC found at Lady Spencer House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- People were generally protected and there were enough staff, with medicines and fire evacuation plans managed safely. However, some bedroom items needed cleaning or replacement, waste arrangements were not always correct, and some PPE was put in general waste bins.
- Effective?
- Good
- People's needs were assessed and care plans were regularly reviewed. Staff had extensive training, people received suitable food and drink, and health referrals were made promptly.
- Caring?
- Good
- People and relatives described staff as kind and respectful. Inspectors saw people being involved in daily choices and supported with privacy, dignity and independence.
- Responsive?
- Good
- Care plans reflected people's needs and preferences. People had a range of individual and group activities, and complaints were handled appropriately.
- Well-led?
- Good
- The manager and provider had strong monitoring systems and sought feedback from people, relatives and staff. Staff training, audits and reviews were used to improve the service.
What inspectors found, March 2023
Lady Spencer House was rated Good overall, but inspectors found infection control and visiting arrangements needed improvement.
This was an unannounced inspection. Inspectors visited the home on 7 February 2023 and reviewed information through 22 February 2023. They observed care, spoke with people, relatives and staff, and checked care, medicines, training and management records.
The home was rated Good overall. Effective, Caring, Responsive and Well-led were all rated Good. Inspectors found kind and respectful care, enough staff, safe medicines practice, good activities and strong management oversight.
Safe was rated Requires Improvement. Some bedroom items needed cleaning or replacement, waste bins were not always suitable or emptied often enough, and staff put some PPE in general waste bins. The home also still required relatives to book visits, although the manager said this would be reviewed.
The previous overall rating was Requires Improvement, published in June 2019, with a breach of Regulation 12. Inspectors found the home had improved and was no longer in breach. Fire safety had also improved after advice was sought from the local fire safety officer.
Enough staff
Inspectors found enough staff on duty and saw that people did not have to wait long for help. The manager used dependency checks and observations to review staffing levels.
“There were enough staff on duty to meet people's needs and they told us that staff responded to their needs quickly.” from the report
Kind and respectful care
People and relatives said staff were kind and respectful. Inspectors saw positive engagement and support that protected privacy and dignity.
“People and their relatives told us they were happy living at Lady Spencer House and were treated with kindness and respect by staff.” from the report
Good staff training
Staff received training linked to their roles and to people's specific needs. The manager also checked staff skills and practice.
“At the time of the inspection there were 54 separate training topics that staff were expected to complete annually.” from the report
Meaningful activities
People could choose from group and individual activities, including bread making, playing the guitar, newspapers, quizzes and word searches.
“There were a range of opportunities on offer for people to choose from.” from the report
Strong management checks
The provider and manager carried out regular audits, observations and competency checks. They used feedback, incidents and complaints to identify improvements.
“There were robust systems in place to support the provider and the manager to carry out regular checks on the quality of the service provided.” from the report
Infection control details
needs fixingSome items in bedrooms needed cleaning or replacing. Some bins were not lidded or were too full, and several general waste bins contained PPE gloves that should have gone into clinical waste bins.
“We found several general waste bins in the service contained PPE gloves.” from the report
Visiting restrictions
needs fixingThe home still used a booking system for visits after wider restrictions had eased. Some relatives felt this reduced how often they could see family members, and inspectors recommended a review.
“Some relatives we spoke with were keen for the provider to resume open visiting.” from the report
Tired environment
minorSome parts of the building and furnishings were tired and needed replacement. A refurbishment programme was under way during the inspection.
“Lady Spencer House is an older style, purpose-built premises which was in need of redecoration and upkeep.” from the report
- 01What changes have been made to bedroom cleaning, bin lids, waste collection and PPE disposal since the inspection?
- 02Can relatives now visit without booking, and how are visiting requests handled if a booking system remains?
- 03Which refurbishment work has been completed, and how were people, including those living with dementia, involved in the design?
- 04How do you check that all recruitment records contain a complete employment history?
- 05How do you monitor staffing levels and make sure people receive help promptly on every shift?
This was an unannounced inspection covering all five key questions, including infection prevention and control, with inspectors visiting the home on 7 February 2023 and inspection activity ending on 22 February 2023. This explanation was written from the published report of 17 March 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.
What inspectors found, February 2022
Inspected but not rated; the home remained Requires Improvement, with infection-control strengths but a breach over vaccination checks and COVID-19 guidance.
This was an unannounced, targeted inspection on 19 and 21 January 2022. One inspector focused on infection prevention and control after a COVID-19 outbreak, including vaccination checks, visiting, testing, cleaning and staffing pressures.
The home had good practices in some areas. Visitors were screened, staff used protective equipment, the home was kept clean, and people and staff took part in regular testing. Inspectors also saw enough staff on shift to meet people's needs safely.
However, vaccination checks and records for staff and professional visitors were not correct. The manager was also not aware of current guidance about admissions, isolation and visits. This breached Regulation 12(3), Safe care and treatment.
This inspection did not give a new overall rating. The previous rating was Requires Improvement, and it remained in place. The home was asked for an action plan and will continue to be monitored.
Clean and hygienic home
Staff kept the home clean and tidy and followed cleaning schedules, protective equipment and hand-sanitising measures.
“People were supported by staff who kept the house clean and tidy and understood the importance of following measures to reduce the risk of spreading infection.” from the report
Visitor screening
Visitors were tested and screened before entering the home.
“Visitors were checked for their COVID-19 status by taking a lateral flow test, having their temperature taken and answering some screening questions prior to entering the building.” from the report
Regular testing
People and staff took part in regular COVID-19 testing, and staff understood extra measures after a positive result.
“People and staff took part in regular testing for COVID-19.” from the report
Enough staff observed
Inspectors observed enough staff on shift to meet people's needs safely.
“We observed there were enough staff on shift to safely meet people's needs.” from the report
Vaccination checks were not reliable
seriousThe home was not correctly checking and recording vaccination evidence for staff and professional visitors who were not exempt. Inspectors said this placed people at risk of COVID-19 infection.
“The provider was not correctly checking and recording the vaccination status of staff and professional visitors (who were not exempt).” from the report
Current guidance was not understood
needs fixingThe manager was not aware of current guidance about admissions, isolation and vaccination checks. This put people's rights around isolation and visiting at risk.
“People's rights in relation to isolation rules were at risk of not being upheld.” from the report
Visiting arrangements did not fully follow guidance
needs fixingInspectors were not assured that visits were being facilitated in line with current guidance.
“We were not assured the provider was facilitating visits for people living in the home in accordance with the current guidance.” from the report
- 01How do you now check and record vaccination evidence for staff and professional visitors who are not exempt?
- 02What process do you use to keep admissions, isolation and visiting arrangements in line with current guidance?
- 03What actions were included in the action plan requested after this inspection?
- 04How do you check that infection-control policies are being followed in practice, not just kept up to date?
- 05What staffing pressures are you experiencing now, and how do you ensure there are enough staff on each shift?
This was an unannounced targeted inspection of infection prevention and control, COVID-19 vaccination requirements and staffing pressures; it did not assess the full key questions or change the previous Requires Improvement rating. This explanation was written from the published report of 17 February 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 Lady Spencer House
4 rated inspections over 8 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2022Inspected but not ratedSafe: Inspected but not rated
- June 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2016Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 11 October 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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