CQC report explained · a residential care home
What the CQC found at Old Rectory (Bramshall)
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found unlocked areas, faulty lighting, fire door problems and weaknesses in medicines management. Staffing levels were considered sufficient, and action was taken quickly on some environmental risks.
- Effective?
- Requires improvement
- Some care plans and assessments were incomplete or inaccurate, and mental capacity assessments were not always decision-specific. Staff received training and support, but records did not clearly show which training had been completed.
- Caring?
- Good
- People were treated with dignity and respect. Staff promoted independence and inspectors observed kind and caring interactions.
- Responsive?
- Good
- Care plans were personalised, activities were arranged and communication needs were considered. Complaints and suggestions were acted on.
- Well-led?
- Requires improvement
- Managers were visible and approachable, and there was a positive culture. However, quality checks did not reliably identify safety risks, inaccurate care records or medicines storage issues.
What inspectors found, February 2024
Rated Requires Improvement; inspectors found kind, person-centred care, but safety, medicines and management systems needed improvement.
This was the first inspection under the current provider. Inspectors visited the home on 14 and 17 November 2023, spoke with people, relatives and staff, and checked care records, medicines, recruitment files and safety records.
The home was not always safe. Inspectors found environmental risks, medicines records that were not always complete, gaps in recruitment records and areas needing more attention with cleanliness. They found no evidence that anyone had been harmed, but said people were at increased risk.
Care was rated Good in Caring and Responsive. People were treated with dignity, staff were kind, care plans were personalised and activities were provided. Safe, Effective and Well-led were rated Requires Improvement because care records, mental capacity assessments, staff training and quality checks were not consistently effective.
The provider acted quickly on some risks found during the inspection, including fitting radiator covers, locking unsafe areas and repairing lighting. The CQC required an action plan and said it would monitor progress with the provider and local authority.
Kind and respectful care
People were treated with dignity and staff supported their independence. Inspectors saw kind interactions and staff taking care to protect people's privacy.
“We observed many kind and caring interactions between people and staff, and staff ensured dignity was promoted” from the report
Personalised support
Care plans reflected people's preferences, and the home arranged activities and supported relationships.
“People's care plans were personalised and considered their own preferences.” from the report
Enough staff on duty
Inspectors found there were enough staff to support people safely. People and relatives also said staffing had improved.
“There were enough staff on duty to support people safely.” from the report
Open management
People, relatives and staff said they could raise concerns with managers. Complaints were responded to and actions were taken.
“Most people could identify members of the management team and felt able to approach registered manager with their thoughts and concerns.” from the report
Environmental safety risks
seriousSome rooms and cupboards were unlocked, some radiators lacked covers, and corridor and emergency lighting was not working. These problems could have exposed people to burns, harmful products or difficulty seeing during an emergency.
“Some storage cupboards and a sluice room were not locked which meant people were at risk of accessing potentially harmful cleaning products stored in these areas.” from the report
Medicines records and storage
seriousSome 'when required' medicine instructions were missing or not detailed enough. Records did not show that pain-relief patches were rotated correctly, and the medicines fridge was outside the required temperature range.
“Some 'when required' medicine protocols were not in place and some were lacking in detail.” from the report
Incomplete care assessments
needs fixingSome people's changing needs had not been fully assessed. Care folders contained inaccurate or conflicting information, and referrals to other professionals were not always evidenced.
“Some people's care plans were not accurate or comprehensive and referrals to external professionals had not been evidenced to demonstrate support had been sought for people when needed.” from the report
Mental capacity assessments
needs fixingMental capacity assessments were not always linked to particular decisions. One assessment contained conflicting information.
“MCA assessments were not decision-specific in line with the principles of the MCA.” from the report
Weak quality checks
seriousThe provider's audits did not reliably identify environmental risks, care record problems or the incorrect medicines fridge temperature. This limited assurance that safety was being managed effectively.
“Governance systems were not robust enough to demonstrate safety was effectively managed.” from the report
- 01What has been done to fix the medicines protocols, patch records and fridge temperature problem, and how is this now checked?
- 02Have all radiators, locks, lighting and fire doors been made safe, and can you show us the latest safety checks?
- 03How do you make sure care plans are updated promptly when someone's needs change?
- 04How are decision-specific mental capacity assessments now completed and reviewed?
- 05What action plan did you send to the CQC, and what improvements have been completed since the inspection?
The inspection looked at the premises and care provided, including all five quality questions, medicines, care records, recruitment, infection control and management systems; it was the first inspection under the current provider. This explanation was written from the published report of 29 February 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.
Every inspection of Old Rectory (Bramshall)
Each visit the CQC has published, newest first, back to the day the home was registered.
- February 2024Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2020
Registered with the Care Quality Commission on 26 November 2020.
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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