CQC report explained · a nursing home
What the CQC found at Northleach Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that environmental risks, building work, medicines, infection control, staffing and safeguarding were managed safely. They found enough improvement for the home no longer to be in breach of Regulation 12.
- Effective?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the last inspection.
- Caring?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the last inspection, although inspectors recorded that people and relatives described staff as caring and kind.
- Responsive?
- Good
- This key question was not inspected during this visit. Its rating was carried over from the last inspection.
- Well-led?
- Good
- Inspectors found clear management roles, improved audits and monitoring, an open culture, and systems for involving people, relatives and staff in the service.
What inspectors found, February 2023
Rated Good; inspectors found improved safety and leadership, but visiting arrangements and some processes were still being reviewed.
This was an unannounced focused inspection on 18 and 19 January 2023. Inspectors checked Safe and Well-led, spoke with people, relatives, staff and professionals, and reviewed care records, risk assessments, medicines, recruitment and quality checks.
The home was rated Good overall. Inspectors found that risks from the building work were managed, medicines were safer, staff followed infection control practices, and people felt safe. Staff knew people's needs and risks, and people and relatives described staff as kind and caring.
The home had improved from Requires Improvement at the previous inspection in 2021. The earlier breach of Regulation 12 had been resolved. Inspectors also found better audits and monitoring systems, with an open approach to learning and improvement.
Improved risk management
The home had made improvements to environmental checks and individual risk assessments. Building work was secured and risks to people were assessed.
“The provider had ensured people's safety and managed the risk to people when building work was being completed.” from the report
Safer medicines
Staff had medicine training and competency checks. An electronic system and monthly audits supported safer administration and record keeping.
“Improvements had been made to the management of people's medicines and the provider had acted upon feedback about the safe management of people's medicines patches.” from the report
Staff knew people well
Inspectors found enough staff with a range of skills and experience. Staff received induction, training, supervision and competency checks.
“There were enough staff recruited with a range of skills and experience to support people.” from the report
Open management
Managers used audits, meetings and feedback to monitor care and learn from incidents. Staff said the manager was approachable and listened to them.
“There was a positive open culture promoted by the registered manager.” from the report
Medicine patch process
needs fixingThe provider was still reviewing its process for applying some medicine patches. Ask what has changed and how the checks work now.
“As part of the inspection the provider was reviewing their processes around patch application for some people.” from the report
Recruitment policy review
minorThe provider was reviewing its recruitment policy to make the approach consistent where staff had worked abroad and in the UK.
“The provider was reviewing their recruitment policy to ensure a consistent approach when staff had worked both abroad and in the UK.” from the report
- 01How are risks from the building work being managed now, and which areas are still affected?
- 02What changes have been made to the process for applying and checking medicine patches?
- 03What are the current visiting times, and can relatives visit in bedrooms and communal areas?
- 04What changes were made to the recruitment policy for staff who have worked abroad and in the UK?
- 05How often are my relative's care plans and risk assessments reviewed when their needs change?
This was a focused inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected and their ratings carried over from the previous inspection. This explanation was written from the published report of 28 February 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, September 2021
Requires Improvement; inspectors found staff available and good communication, but risks and medicines were not always managed safely.
This was an unannounced, focused inspection after concerns about infection control, staffing and nursing care. Inspectors visited on 20 and 22 July 2021 and continued their work virtually until 23 July. They spoke with people, relatives and staff, observed care and checked care, medicine, staffing and management records.
The home was not always safe. Some risks were not recorded or managed properly, care plans were incomplete or overdue for review, and medicines were not always handled safely. Inspectors found gaps in medicine records, evidence of missed medicines, unlabelled opened medicine boxes and medicine fridge temperatures outside the required range.
The home was also not always well-led. Its audits did not reliably find important problems, so inspectors recommended stronger checks. Staff were available during the inspection and recruitment checks were completed properly. The overall rating fell from Good to Requires Improvement, while the other three key-question ratings were carried over because they were not inspected.
Staffing observed
Inspectors saw enough staff to meet people's needs during the visit. Rotas showed that staffing levels were maintained.
“At the time of the inspection, we saw there were adequate staff to support people's needs.” from the report
Safe recruitment
The required recruitment checks were completed before staff started work, including criminal record checks, references and nurses' registration checks.
“All required checks were made before new staff began working with people in the home.” from the report
People felt safe
People and relatives told inspectors that people felt safe. Staff understood safeguarding procedures and knew the people they supported.
“People and their relatives told us they felt people were safe.” from the report
Communication with relatives
Relatives said communication was good and that they were involved. Relative meetings continued online during the pandemic.
“People and their relatives told us communication between themselves and the home was good and they were supported to be involved.” from the report
Medicines
seriousMedicines were not always given, recorded or stored safely. Inspectors found evidence of missed medication and other medicine management problems.
“There were gaps in medication records, evidence of missed medication, boxes of medicines not labelled when opened and medicine fridge temperatures found to be outside of the required temperature range.” from the report
Risk records and care plans
seriousSome care plans did not include important information or had not been reviewed on time. This included a risk linked to blood-thinning medicines and unclear guidance about distressed behaviour.
“People's care plans did not always identify key pieces of information and had not always been reviewed in accordance with the provider's policy.” from the report
Weak quality checks
needs fixingThe home's audits did not reliably identify problems with medicines, infection control, fluid intake, risk plans and hot-weather safety. Inspectors recommended independent checking of the audit system.
“We recommend the provider develops their processes to ensure their audits and other monitoring systems are able to effectively assess, monitor and mitigate risks to people.” from the report
Mixed staffing feedback
needs fixingRelatives and professionals gave mixed feedback about whether there were enough care staff. Agency staff were being used for vacant posts and staff leave, although staffing was adequate during the inspection.
“Although we received mixed feedback from professionals and relatives about whether there were enough care staff to manage people's needs, at the time of the inspection, we saw there were adequate staff to support people's needs.” from the report
Use of protective equipment
minorInspectors were not fully assured that protective equipment was being used effectively and safely.
“We were somewhat assured that the provider was using PPE effectively and safely.” from the report
- 01What has changed since the inspection to prevent missed medicines and gaps in medicine records?
- 02How do you now check medicine fridge temperatures and label medicine boxes when they are opened?
- 03How are risks such as blood-thinning medicines, hot weather and low fluid intake recorded, reviewed and acted on?
- 04What independent checks are now made to ensure audits identify problems accurately?
- 05What are the current staffing levels, how many agency staff are being used, and how are vacant posts being filled?
This was a focused inspection of Safe and Well-led, including infection control; Effective, Caring and Responsive were not inspected and their previous ratings were carried over. This explanation was written from the published report of 14 September 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 Northleach Court Care Home
3 rated inspections over 3 years: the service has held its Good rating throughout.
- February 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2021Requires improvementSafe: Requires improvementWell-led: Requires improvement
- January 2021Inspected but not ratedSafe: Inspected but not rated
- March 2020GoodSafe: GoodWell-led: Good
- January 2019
Registered with the Care Quality Commission on 24 January 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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