CQC report explained · a residential care home
What the CQC found at Naylorsfield and Hartsbourne
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2024
Rated Inadequate and placed in special measures; inspectors found unsafe care, unlawful restrictions, poor conditions and weak management.
Inspectors visited on 10, 15 and 18 January 2024. They spoke with five people and 11 staff, walked around the home, and checked care plans, medicines, recruitment files and management records.
They found serious problems with safety, cleanliness, medicines, risk assessments and the way incidents were handled. Some people had restricted access to food and windows without the required checks or involvement in decisions. Bedrooms were unclean and some essential equipment, including ovens, had not been repaired.
People were not always supported to make choices, be independent, follow their interests or take part in activities. Staff were described as kind and respectful in some situations, but the home did not consistently provide person-centred care or protect dignity and privacy.
The overall rating changed from Good at the previous inspection to Inadequate. Safe and Well-led were rated Inadequate, while Effective, Caring and Responsive Requires Improvement.
Kind staff
Inspectors found that staff were kind and respectful in their approach and knew people's usual preferences.
“Staff were kind and respectful in their approach towards people and were knowledgeable about their day-to-day preferences.” from the report
Safe recruitment
The home completed appropriate checks before employing staff, and inspectors found enough staff were deployed to meet people's needs.
“Staff were safely recruited. Appropriate checks had been made before being offered employment.” from the report
Healthcare support
People were supported to use healthcare services, and staff worked with outside professionals to manage health conditions.
“People's health conditions were managed appropriately, and staff engaged with external healthcare professionals for example GP's, social workers and speech and language therapists.” from the report
Some immediate action
The provider responded to some concerns during the inspection, including removing window restrictors and buying temporary cooking equipment.
“The registered manager and provider were receptive to our feedback and addressed some issues quickly such as the issues with access to food, window restrictors and staff use of lanyards and keys.” from the report
Poor risk management
seriousSome risks were not assessed or managed properly. Incident records lacked detail and there was little evidence that lessons were learned to prevent further harm.
“The provider failed to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Unclean and poorly maintained areas
seriousSome bedrooms were visibly dirty and unhygienic, with mould, old food and stained bedding. Damaged furniture and broken ovens also affected the living environment.
“Parts of the service in particular people's bedrooms were visibly unclean, unhygienic, and poorly maintained.” from the report
Unsafe medicines arrangements
seriousMedicines were kept in a room that was too hot, some as-needed medicines lacked protocols, and some staff medicines training was out of date or incomplete.
“Medicines were not stored safely as the room temperature exceeded the recommended maximum room temperature required to ensure medicines remained effective.” from the report
Restrictions without proper consent
seriousAccess to food and windows was restricted without evidence that people or their representatives were consulted or that decisions were made in their best interests.
“The provider failed to work within the requirements of the MCA when imposing restrictions upon people.” from the report
Food and daily life
seriousFood stocks were limited and people could not freely access snacks between meals. Some people were unable to follow their usual activities and interests because of financial restrictions.
“The provider failed to ensure people's nutrition and hydration needs were assessed and planned for and that they had access to a variety of suitable and nutritious food.” from the report
Weak management oversight
seriousAudits and governance systems did not identify serious problems with care, safety, restrictions or records. Some important incidents were not reported to CQC promptly.
“The provider failed to operate effective systems and processes to assess and monitor the quality and safety of the service.” from the report
- 01What has been done to complete and regularly review risk assessments and to learn from accidents and incidents?
- 02How are medicines now stored, and are all staff training and competency checks up to date?
- 03How can people access food and snacks, and how are their nutrition and hydration needs recorded and monitored?
- 04How are restrictions on windows, food or daily activities now authorised, reviewed and agreed in line with the Mental Capacity Act?
- 05What changes have been made to cleaning, bedroom conditions, cooking equipment and management audits since the inspection?
This was a focused inspection that examined all five key questions, including infection prevention and control under Safe; the report says the ratings changed based on this inspection. This explanation was written from the published report of 22 March 2024 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, April 2020
Naylorsfield and Hartsbourne was rated Good overall, with Outstanding support for people's health, choices and independence.
This was a planned first inspection of the newly registered home. One inspector visited on 06 February 2020, spoke with all three people living there, six staff members and professionals, and reviewed care, medicines, staff and management records.
Inspectors found people were safe, treated with kindness and involved in decisions about their lives. Staff supported people with complex needs, helped them access health services and encouraged activities, education, relationships and independence.
The home was rated Good overall. Safe, caring, responsive and well-led were rated Good. Effective was rated Outstanding, meaning people's outcomes were consistently better than expected compared with similar services.
Exceptional outcomes
Inspectors found that support had made a significant positive difference to people's lives, including helping them access health care and important opportunities.
“Outcomes for people were exceptional given the short time they had lived in the home.” from the report
Choice and independence
People were involved in decisions about daily life, activities, food and personal goals. Care plans reflected their abilities and aspirations.
“People had control and choice in planning their daily activities and achieving their goals.” from the report
Skilled staff
Staff received training relevant to people's complex needs, including specialist training. Inspectors found staff knowledgeable about safeguarding and medicines.
“We found that numerous specialist training events had been attended so staff were well equipped to support those people with complex histories.” from the report
Kind and respectful care
Inspectors saw positive relationships between staff and people. People said they were treated well and could raise worries with staff.
“We saw positive interactions between people living in the home and the staff.” from the report
Good leadership
The manager was available to people and staff, and audits were used to identify and address problems with the environment and care.
“The management, auditing and open-door policy within the service was effective in driving up the standards of care delivered to people in the home.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you continue to explore and record my relative's wishes about end of life care?
- 02What level of one-to-one or two-to-one staffing would my relative receive, and how is this kept consistent?
- 03What restrictions might apply to my relative, and how will you make sure they are the least restrictive option?
- 04How would you support my relative to attend medical appointments if they were anxious or had refused care in the past?
- 05How would you adapt information or documents if my relative needed a different format or larger print?
This was a planned first inspection of the newly registered home, covering all five CQC questions and both the accommodation and care provided; nobody was receiving end of life support at the time. This explanation was written from the published report of 4 April 2020 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 Naylorsfield and Hartsbourne
2 rated inspections over 4 years: the service has slipped, from Good to Inadequate.
- March 2024Inadequatecurrent ratingdown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
Read what inspectors found at Naylorsfield and Hartsbourne →
- April 2020GoodSafe: GoodEffective: OutstandingCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Naylorsfield and Hartsbourne →
- February 2019
Registered with the Care Quality Commission on 22 February 2019.
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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Most charge £980 to £1,260 a week. 83 can care for a couple. 10 years' experience on average.
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