CQC report explained · a nursing home
What the CQC found at Northenden House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found safe medicines management, robust risk assessments, safeguarding systems and sufficient staffing. Infection prevention arrangements were also judged satisfactory.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found clear management roles, regular audits, learning from incidents and good involvement of people, relatives and staff.
What inspectors found, May 2023
Northenden House is rated Good; inspectors found safe, kind and person-centred care, with some maintenance still being addressed.
This was an unannounced focused inspection. One inspector visited on 30 March 2023 and reviewed records, medicines, staffing, safety checks and management systems. They observed care, activities and a medicine round, and spoke with seven staff members.
The home was rated Good for Safe and Well-led. Inspectors found that medicines were managed safely, risks were assessed, safeguarding systems were in place and staffing was sufficient. People were supported to make choices, take part in activities and access the community.
The previous inspection rated the service Requires Improvement because medicines records were not accurate and Regulation 17 had been breached. This inspection found enough improvement, so the home was no longer in breach. The overall rating changed to Good, but the other three areas were not inspected during this visit and their previous ratings were carried forward.
Safe medicines
Medicines records were complete, storage was secure and nurses carried out regular checks. The previous medicines recording problem had been addressed.
“Medication administration records (MAR's) were completed in full with no errors or omissions.” from the report
Personalised support
Staff knew people well and supported their choices, independence and individual needs. Care plans were regularly reviewed and reflected the care provided.
“People received kind and person-centred care. Staff responded to individuals needs well and supported them appropriately.” from the report
Community activities
People were supported to take part in meaningful activities and go into the community, including trips to the park, shop and farm.
“People were supported to take part in meaningful activities including having access to the community, this included trips to the park, the shop and a farm.” from the report
Maintenance needed
minorSome maintenance was still needed after damage caused by a previous resident. The report says this was being addressed, but it does not say when it would be completed.
“The home required some maintenance following some damage from a previous resident however this was being looked at by the service.” from the report
Domestic support
minorStaff said they would benefit from a dedicated domestic worker. The report still judged staffing sufficient, but this could affect how much time staff have for care and support.
“staff told us they would benefit from a dedicated domestic staff member to allow them to focus on care and support.” from the report
- 01What maintenance work is still outstanding, and when will it be completed?
- 02Have you added dedicated domestic support since the inspection?
- 03How do you make sure medicines records remain complete and accurate?
- 04How are people supported to choose activities and access the local community?
- 05What changes were made after the previous inspection's concerns about medicines records?
This was a focused inspection of Safe and Well-led only; the other three ratings were carried over from the previous inspection. This explanation was written from the published report of 5 May 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, May 2022
Northenden House was rated Requires Improvement; inspectors found kind, person-centred care but medicines management and oversight were not reliable enough.
This was an unannounced focused inspection. Inspectors visited from 15 to 19 March 2022, observed care and activities, spoke with people, staff, relatives and professionals, and checked care, medicines, recruitment and management records.
People were supported to make choices, stay independent and take part in activities. Inspectors saw kind and compassionate care, respectful staff and support that reflected people's communication needs and personal routines.
The home had improved its staffing, fire safety, equipment checks and quality monitoring. However, medicine records were not always accurate, returned medicines were not stored in line with guidance, and some checks did not identify these problems.
The overall rating was Requires Improvement. Safe and Well-led were also rated Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were used in the overall rating.
Kind and respectful care
Inspectors saw people receiving compassionate care. Staff protected people's privacy and dignity.
“People received kind and compassionate care. Staff protected and respected people's privacy and dignity.” from the report
Support for communication needs
Staff understood different ways people communicated, including body language, sounds, signs, pictures and symbols.
“People who had individual ways of communicating, using body language, sounds, Makaton (a form of sign language), pictures and symbols could interact comfortably with staff and others involved in their care and support because staff had the necessary skills to understand them.” from the report
Staffing and activities
Staffing levels were sufficient during the inspection. People were supported to follow their chosen activities and interests.
“Staffing levels were appropriate to meet the needs of the people using the service.” from the report
Improved safety arrangements
The home had improved its fire safety, equipment maintenance and infection control arrangements.
“We found improvements to the homes fire safety arrangements, with a new fire risk assessment in place and enhanced fire drills taking place.” from the report
Medicine records and storage
seriousMedicine directions were not always copied correctly onto administration charts. Returned medicines and medicine fridge temperatures were also not managed fully in line with guidance.
“Medicines records were not always accurate, which meant there was a risk medicines might be given unsafely.” from the report
Incident analysis
needs fixingStaff responded to incidents, but the home needed to examine them in more detail to identify patterns and help prevent them happening again.
“However, the service needed to analyse incidents such as Antecedent, a Behavior, and a Consequence (ABC forms) in greater detail to look for any potential trends or patterns to prevent recurrences of incidents.” from the report
Use of current guidance
minorCQC recommended that the provider update its practice and staff learning against the Right Support, Right Care, Right Culture guidance.
“We found the service was not fully up to speed with this key guidance.” from the report
- 01What changes have been made to ensure medicine directions are copied accurately onto administration charts?
- 02How are returned medicines now stored and how are medicine fridge temperatures recorded?
- 03How are incidents and ABC forms now analysed for patterns and repeated risks?
- 04Who is currently responsible for managing the home, and how often are they on site?
- 05What action has been taken in response to the Right Support, Right Care, Right Culture recommendation?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 27 May 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 Northenden House
4 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- May 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- September 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- August 2019Requires improvementSafe: Requires improvementWell-led: Requires improvement
- May 2018
Registered with the Care Quality Commission on 17 May 2018.
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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