CQC report explained · a nursing home
What the CQC found at Littleover Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that the home was managing COVID-19 risks, including visitors, PPE, testing, cleaning, admissions and outbreaks. They were also told that measures were in place to reduce the impact of COVID-19-related staffing pressures.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Requires improvement
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, January 2022
Inspected but not rated; inspectors were assured that infection control and COVID-19 safety measures were in place.
This was an announced, targeted inspection on 13 January 2022. It checked infection prevention and control during a COVID-19 outbreak, and asked about staffing pressures.
Inspectors found visitor screening, temperature checks, hand hygiene facilities, regular cleaning and appropriate protective equipment. Staff and residents had regular COVID-19 testing, and staff were split into teams to reduce infection spread.
The inspectors said they were assured about infection control, safe admissions, protective equipment, testing, cleaning, outbreak management and visiting arrangements. The home was also meeting the requirement about COVID-19 vaccination for non-exempt staff and visiting professionals.
The service was inspected but not rated. This was not a full assessment of all five areas of care.
Visitor screening
Visitors were screened when they entered, with temperature checks, hand washing facilities and hand gel available.
“A COVID - 19 screening questionnaire and track and trace details was required for all visitors, to complete upon entry.” from the report
Reducing infection spread
During the outbreak, separate staff teams supported people with and without a positive COVID-19 test result.
“During the COVID - 19 outbreak at the home, there was two staff teams on each shift.” from the report
Staff training and PPE
Staff had infection control training and inspectors observed them using PPE appropriately.
“Staff had received training in infection prevent and control and the use of personal protective equipment (PPE).” from the report
Testing and vaccination
People and staff accessed regular COVID-19 testing. The service also met the vaccination requirement for non-exempt staff and visiting professionals.
“The service was meeting the requirement to ensure non-exempt staff and visiting professionals were vaccinated against COVID-19.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection control arrangements are currently in place for visitors?
- 02How are staff teams organised if there is a COVID-19 outbreak?
- 03How often are residents and staff currently tested for COVID-19?
- 04How do you check that staff and visiting professionals meet the current vaccination or exemption requirements?
- 05What is the home's current overall CQC rating, given that this inspection was not rated?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; it did not provide ratings for the other areas of care. This explanation was written from the published report of 25 January 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.
What inspectors found, May 2021
Littleover Nursing Home rated Good; a focused inspection found improved infection control, staffing and management, but did not reassess three care areas.
Inspectors made an unannounced focused visit on 7 April 2021. One inspector visited the home and another spoke to relatives by telephone. They spoke with people, relatives and staff, and checked care, medicines, recruitment, complaints, incidents, audits and safety records.
The home was rated Good for Safe and Well-led. Inspectors found suitable infection control measures, including staff training, appropriate protective equipment, regular testing and increased cleaning. Staffing was based on people's needs, recruitment checks were completed, and medicines and risk assessments were managed safely.
The home had improved since its previous inspection, which had been rated Requires Improvement. Previous problems with infection control, management oversight, equipment checks, training and records had been addressed. The provider was no longer in breach of Regulations 12 and 17.
This was a focused inspection because concerns had been received about care and support. Inspectors only checked Safe and Well-led. The ratings for Effective, Caring and Responsive were not reassessed and carried over from the earlier comprehensive inspection.
Infection control
Staff used protective equipment correctly and had infection control training. Cleaning, testing and arrangements for visitors were in place to reduce the spread of COVID-19.
“People were protected from the spread of infection and cleaning had been increased during the onset of COVID-19.” from the report
Staffing and recruitment
Staffing levels were calculated from people's needs. The home completed criminal record checks and references before staff started work.
“Staff were recruited safely. Appropriate checks were made prior to staff starting in post to ensure that they were suitable to work with vulnerable adults.” from the report
Medicines and risk management
Medicines were audited, stored safely and given by trained staff. Care plans and risk assessments were reviewed when people's needs changed.
“Best practice guidance in the management of medicines was consistently followed.” from the report
Improved management
The home had acted on problems found at the previous inspection. Equipment checks, quality monitoring and management oversight had improved.
“They had used the feedback from the last inspection to make improvements in all of the areas of risk identified.” from the report
Kind and approachable staff
Relatives described staff and management as kind and caring. People and relatives said they felt able to raise concerns.
“Relatives told us that the staff and registered manager were kind and caring.” from the report
Further improvement work remained
minorThe registered manager accepted that more work was still needed, although inspectors found that risks had been reduced. Families may want to ask how this remaining work is tracked and reviewed.
“The registered manager acknowledged that they still had more to do, but they were satisfied that risks to people's safety had been reduced.” from the report
- 01What further improvement work did the registered manager say was still needed, and how is it being checked?
- 02How often are staffing dependency assessments reviewed when a resident's needs change?
- 03How are medicines audits used to identify and correct any administration errors?
- 04How often are wheelchairs, hoists, slings, beds and nurse call bells checked and serviced?
- 05What was the previous rating for Effective, Caring and Responsive, and when will these areas next be fully inspected?
This was an unannounced focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 7 May 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.
Every inspection of Littleover Nursing Home
5 rated inspections over 5 years: the service has held its Good rating throughout.
- January 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- May 2021Goodup from Requires improvementSafe: GoodEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Good
- January 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- May 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 7 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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