CQC report explained · a nursing home
What the CQC found at Orton Manor Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk management, wound monitoring, falls records and medicines management had improved. However, some food and fluid records were incomplete or difficult to compare, environmental issues remained, and temporary workers' COVID-19 vaccination status was not routinely checked.
- Effective?
- Good
- This focused inspection did not assess Effective. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This focused inspection did not assess Caring. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This focused inspection did not assess Responsive. Its previous rating was used in calculating the overall rating.
- Well-led?
- Requires improvement
- Provider oversight, management visibility, meetings and electronic records had improved. However, staffing vacancies remained and the new systems needed to become part of the home's culture and continue when more people moved in.
What inspectors found, March 2022
Rated Requires Improvement; inspectors found important improvements after an Inadequate rating, but safety and management systems were not yet consistently reliable.
This was an unannounced focused inspection on 8 February 2022. Inspectors checked whether the home had acted on previous warning notices about safe care and treatment and good governance. They spoke with people, relatives, staff and managers, and reviewed care records, wound charts, medicines records and management records.
The home had improved since the previous inspection. Risk plans, wound monitoring, falls records and medicines management were better. There were enough staff on the inspection day, but vacancies meant the home still relied heavily on agency staff.
Some problems remained. Food and fluid records were not always easy to use, some environmental risks were found, temporary workers' COVID-19 vaccination status was not routinely checked, and accidents were not reviewed overall for patterns. The home was no longer in breach of Regulations 12 and 17, but the inspection identified a breach linked to vaccination checks.
The overall rating and the ratings for Safe and Well-led were Requires Improvement. The home had previously been rated Inadequate and placed in Special Measures, but it was no longer rated Inadequate or in Special Measures after this inspection.
Better risk management
Risk plans were in place and staff could access them. Wound, skin damage and falls monitoring had also improved.
“Where risks had been identified, risk management plans were in place and were accessible to staff.” from the report
Improved medicines systems
Medicines records were more accurate and included better guidance for medicines given when needed. People who had previously received hidden medicines had been reviewed by a GP and were no longer receiving them that way.
“Since our last inspection there had been significant improvements in the safe management of medicines.” from the report
More visible management
The provider was visiting every week, and the new managers were visible and available. Meetings helped staff understand their roles and risks.
“The provider was visiting the home every week to speak with managers and staff and ensure actions identified on the service improvement plan (SIP) were achieved.” from the report
Improved staff teamwork
Staff said communication and morale had improved. They felt more able to raise concerns and work together.
“Morale in the home had improved and staff were beginning to work more effectively together as a team.” from the report
Temporary worker checks
seriousThe home did not routinely check the COVID-19 vaccination status of temporary workers supplied by an agency. The report identified this as a breach.
“We identified a breach of Regulation 12(3), as the vaccination status of temporary workers supplied via an agency was not routinely checked.” from the report
Food and fluid records
needs fixingFood charts did not always show what people had eaten. Fluid records were kept in different parts of the electronic system, making comparisons harder.
“However, some improvements were still required. For example, food charts did not always record what people had actually eaten, and fluid input and output charts were kept within different areas on the electronic care system.” from the report
Environmental risks
needs fixingInspectors found exposed pipes, a portable heater without a risk assessment and a drainage problem in a communal bathroom. The provider later sent evidence that these issues had been addressed.
“We found exposed pipes in the downstairs communal bathroom, a portable heater was being used by a person with no risk assessment and the water drainage system in one communal bathroom was still not working efficiently.” from the report
Accident trend monitoring
needs fixingIndividual accidents and incidents were reviewed, but the home did not analyse them together to look for wider patterns or trends.
“However, there was no overall analysis of accidents and incidents to identify any trends or patterns.” from the report
Reliance on agency staff
minorThere were enough staff on the inspection day, but staff vacancies meant the home continued to rely heavily on agency workers. Inspectors said improvements needed to last when new people moved in.
“There were still a significant number of staff vacancies at the service and whilst the provider was recruiting new staff, there was still a heavy reliance on agency staff to cover those vacancies.” from the report
- 01How do you now check and record the COVID-19 vaccination status of every temporary worker supplied by an agency?
- 02How do you check that food, fluid input and fluid output records are complete and reviewed together?
- 03What action has been taken to prevent the environmental problems found in the communal bathroom and to risk-assess portable heaters?
- 04How are accidents and incidents now reviewed together to identify patterns or repeated risks?
- 05How are you reducing reliance on agency staff, and how will you make sure recent improvements continue when new people move into the home?
This was an unannounced focused inspection of Safe and Well-led; the other key question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 9 March 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, January 2022
Orton Manor Nursing Home was rated Inadequate and placed in special measures; inspectors found serious problems with risk management, medicines and oversight.
This was an unannounced, focused inspection on 18 November 2021. Inspectors looked only at Safe and Well-led. They spoke with people, relatives and staff, and reviewed care records, medicines records and management checks.
Inspectors found that risks were not always identified or managed. Records did not show that all planned care had been provided safely. There were concerns about catheter care, wounds, falls, oral care, medicines and fire safety. Some infection control and equipment problems were also found.
The home had enough staff during the visit, but relied heavily on agency staff. Management checks were not completed properly, so important problems were missed. Safe and Well-led were both rated Inadequate, and the overall rating fell from Good at the previous inspection in 2017.
Staffing during the visit
There were enough staff on duty during the inspection to meet people's needs. However, the home relied heavily on agency staff and had no permanent night nurses.
“Records showed enough staff to meet the needs of the people living at the home, however there was a heavy reliance on agency staff.” from the report
Some infection controls
Inspectors were assured about visitor infection controls, social distancing, admissions, testing, PPE use in most areas and visits.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Safeguarding policy
The home had a safeguarding policy and the interim manager understood the duty to report concerns to the relevant authorities. However, gaps in records created a risk that some concerns might not be identified.
“The provider had a safeguarding policy which was available for staff to refer to.” from the report
Risks and care records
seriousImportant risks were not consistently assessed or managed. Inspectors found gaps in records about catheters, wounds, falls, fluid intake, bowel care, oral care and injuries.
“Risk was not always identified, assessed and well-managed.” from the report
Medicines
seriousMedicine administration records had gaps and stock balances were inaccurate. Inspectors could not be assured that people always received medicines as prescribed.
“This meant we could not be assured people always received their medicines as prescribed.” from the report
Fire and environmental safety
seriousFire safety failures identified by the fire service had not been dealt with sufficiently. Inspectors also found unsafe window restrictors and problems with cleanliness and equipment.
“Failures to comply with The Regulatory Reform (Fire Safety) Order 2005 had been identified but little action had been taken to mitigate these failures.” from the report
Weak management checks
seriousAudits and checks were not completed as scheduled. This meant management did not identify or act on important safety and care problems.
“The provider had failed to maintain sufficient and accurate oversight of the service and to identify risk management was ineffective and that regulations were not being met.” from the report
Accident reporting
needs fixingStaff had not been trained to use the electronic incident system. There was also a four-month gap in accident and incident records.
“This meant we could not be sure action had been taken to mitigate individual risks or identify any trends or patterns at service level.” from the report
Infection and equipment problems
needs fixingInspectors found a dirty suction machine, a damaged grab rail, poor drainage, dirty bedrail covers and problems with sharps disposal. Some PPE was also not easy to access.
“The suction machine to clear secretions was out of reach on a high shelf in the clinic room.” from the report
- 01What has been done to make sure falls, wounds, catheter care, fluid intake and oral care are assessed and recorded correctly?
- 02How are medicines now checked, including missing signatures, stock balances, 'as required' medicines and medicines given covertly?
- 03What action has been completed to address the fire service's findings, including the fire risk assessment, fire-resistant furnishings and bedroom door gaps?
- 04How many permanent nurses and care staff are now employed, and how is the home reducing its reliance on agency staff?
- 05How often are care, medicines, health and safety audits now completed, and who checks that identified problems are put right?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 27 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.
Every inspection of Orton Manor Nursing Home
4 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- March 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2022Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- October 2017Goodup from Requires improvementSafe: Requires improvementWell-led: Good
- October 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- November 2013
Registered with the Care Quality Commission on 17 November 2013.
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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