CQC report explained · a residential care home
What the CQC found at Larkhill Hall
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2023
Overall rated Requires Improvement, with Safe rated Inadequate because medicines were not managed safely and some care records were unreliable.
This was an unannounced, focused inspection on 7 June 2023. Two inspectors spoke with people, staff and relatives, and checked care records, medicine records, recruitment files and management systems.
The biggest concern was medicines. Some people did not receive medicines as prescribed or on time, and four people had missed medicines because they were out of stock. The inspectors also found conflicting care records about diets and missing evidence of some weight checks.
There were positive findings too. People and relatives said staff were kind and communicated with families. Inspectors found enough staff, safe recruitment, suitable infection control and appropriate safeguarding arrangements.
The overall rating was Requires Improvement. Safe was rated Inadequate and Well-led was rated Requires Improvement. The other three key question ratings were not given in this focused inspection.
Kind staff
People, relatives and staff gave positive feedback about the care team. Inspectors observed caring and supportive interactions.
“We observed caring and supportive interactions between people living at the service and staff.” from the report
Enough staff
Inspectors found enough staff on duty to meet people's needs, and recruitment checks were completed safely.
“Observations showed there were enough staff deployed to meet people's needs.” from the report
Infection control
The home was visibly clean, had enough protective equipment and was managing infection prevention appropriately.
“Infection prevention and control procedures were being effectively managed.” from the report
Safeguarding arrangements
Staff knew how to report concerns, and incidents and accidents were reviewed to reduce the chance of them happening again.
“Staff were aware of safeguarding processes and how to escalate concerns regarding abuse.” from the report
Missed or late medicines
seriousSome people did not receive medicines as prescribed or on time. Four people had missed some medicines because they were out of stock, and records were incomplete.
“Unsafe medication practices were observed that placed people at risk of harm through not receiving their medicines as prescribed or on time.” from the report
Medicine checks did not work
seriousMedicine records were difficult to follow and stock checks were inaccurate. The home's own audits had not identified all the problems.
“The auditing systems in place for medication were ineffective and failed to evidence improvements.” from the report
Incorrect or unclear diets
seriousSome care plans and risk assessments recorded different diets. Inspectors were not assured that people always received the modified diets recommended for their needs.
“Failure to follow the recommended modified diet placed the person at risk of avoidable harm.” from the report
Weak governance
seriousManagement systems had not led to timely, effective improvement. Some problems found at the previous inspection were still present.
“The governance systems were still not robust enough to ensure that risks to people's health and welfare were managed sufficiently to protect them from harm.” from the report
- 01What has changed since the inspection to make sure every medicine is available and given at the correct time?
- 02How are medicine administration records and stock balances checked now, and who reviews these checks?
- 03How do you make sure each person's current modified diet is clearly recorded and followed by all staff?
- 04How are weekly weights and dietician recommendations recorded and checked?
- 05What action has been taken in response to the warning notice and the continued Regulation 17 breach?
This was an unannounced focused inspection of Safe and Well-led; the other three key question ratings were not given in this inspection. This explanation was written from the published report of 21 September 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, December 2022
Larkhill Hall was rated Requires Improvement; inspectors found caring support and enough staff, but medicines records and quality checks were not reliable enough.
This was an unannounced focused inspection on 19 October 2022. Inspectors looked at Safe and Well-led, after concerns about medicines and staffing. They spoke with people, relatives, staff and the manager, and checked care records, medicine records, staff files and other documents.
The home was not always safe because medicine records did not always show that medicines had been given correctly. Records for time-sensitive medicines and pain patches were incomplete, and some plans for medicines given when needed lacked enough guidance. Inspectors found no evidence that anyone had been harmed, but said these problems created a risk of avoidable harm.
Staff knew people well, staffing levels were sufficient, and people and relatives said they felt safe and were happy with the care. The home was clean, infection control arrangements were in place, and accidents and safeguarding concerns were acted on.
The overall rating changed from Good to Requires Improvement. The manager acted promptly when inspectors raised concerns, but the provider's audits had not found all the medicines problems. CQC said it would request an action plan and continue to monitor the home.
Enough staff
Inspectors found staffing levels were sufficient for people's needs. Recruitment checks were also completed to assess whether new staff were suitable.
“Staffing numbers were based upon people's level of dependency. Observations showed there were enough staff deployed to meet people's needs.” from the report
People felt safe
People and relatives told inspectors they felt safe and were confident that relatives were looked after well. Accidents, incidents and safeguarding concerns were reviewed and acted on.
“Accidents, incidents and safeguarding concerns were recorded and acted upon appropriately.” from the report
Clean home and infection control
The home and mobility equipment were clean and hygienic. Staff were seen using and disposing of protective equipment correctly.
“The home and equipment used by people for mobility were observed to be clean and hygienic.” from the report
Positive care culture
People and relatives gave positive feedback about the care, communication and activities. Inspectors observed that the manager wanted care to be person-centred.
“Positive feedback was received from people and family members about the service and the standard of the care provided.” from the report
Medicine records
seriousMedicine administration records were not always completed accurately. This included records for time-sensitive medicines and pain patches, and created a risk of avoidable harm.
“Medicine administration records were not always completed to show when people's prescribed medicines had been administered” from the report
Plans for medicines given when needed
needs fixingSome plans did not give enough personalised information to help staff decide when medicines given as needed should be administered.
“Where people were prescribed 'as required' medicines, plans did not always provide person-centred information to ensure staff were only administering these medicines when needed.” from the report
Quality checks missed problems
needs fixingThe provider's audits had found some issues, but they had not identified all the medicines problems found by inspectors. CQC recommended more robust checks.
“However, some of the issues we found in relation to medicines management had not been identified through the provider's own audits.” from the report
- 01What changes have you made to ensure every medicine administration record is completed accurately?
- 02How do you now check that time-sensitive medicines and pain patches are given and recorded at the correct times?
- 03How are plans for medicines given when needed made specific to each resident?
- 04What action was included in your improvement plan, and how is progress being checked?
- 05Who is currently responsible for the home while the manager's CQC registration is being completed?
This was a focused inspection of Safe and Well-led only; the other key-question ratings and parts of the overall rating were carried over from the previous inspection. This explanation was written from the published report of 21 December 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 Larkhill Hall
6 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- September 2023Requires improvementcurrent ratingstayed Requires improvementSafe: InadequateEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
- August 2021Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- January 2021GoodSafe: GoodWell-led: Good
- November 2020Inspected but not ratedSafe: Inspected but not rated
- March 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- March 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2016
Registered with the Care Quality Commission on 1 February 2016.
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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