CQC report explained · a nursing home
What the CQC found at Overbury House Nursing and Residential 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
- Medicines were not always administered, recorded or ordered safely. Other safety arrangements included risk assessments, recruitment checks, safeguarding training and satisfactory infection control.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused inspection. Relatives nevertheless told inspectors that staff were caring and kind.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- The home's audits had not identified or addressed medicines problems, and communication with relatives was not always effective. Relatives and staff also described the manager as approachable.
What inspectors found, September 2023
Rated Requires Improvement; inspectors found unsafe medicines management and weaknesses in quality checks, although staff were caring and other safety systems were in place.
This was an unannounced focused inspection. Inspectors visited the home on 25 July 2023, spoke with relatives and staff, and reviewed care, medicines, recruitment and management records. They also made telephone calls to relatives and gave feedback on 16 August 2023.
The main problem was medicines. Some records had gaps or errors, guidance for medicines given when needed was missing, and medicines were not always ordered in time. The provider's checks had not found these problems. This led to a breach of Regulation 12 on safe care and treatment.
Inspectors found staff were kind and trained, care plans contained information about risks, and infection control arrangements were satisfactory. However, relatives gave mixed views about staffing and communication was not always effective.
The overall rating changed from Good at the previous inspection to Requires Improvement. This inspection looked only at Safe and Well-led. The other question ratings were carried forward from the previous inspection.
Caring staff
Relatives said staff were caring and kind. Inspectors also saw staff supporting people with medicines patiently.
“all relatives found the staff to be caring and kind.” from the report
Risk information
Care plans and risk assessments gave staff information about people's needs, including choking risks. Referrals to specialist teams were recorded.
“Care plans and risk assessments contained information for staff to manage risks.” from the report
Safeguarding and recruitment
Staff had safeguarding training and understood how to respond to possible harm. Recruitment checks, including references and DBS checks, were in place.
“Staff had completed safeguarding awareness training and were confident in actions to take in keeping people safe from harm and abuse.” from the report
Visits and infection control
There were no visiting restrictions, and families were made welcome. Inspectors were assured about infection prevention and control arrangements.
“Friends and families were encouraged to visit the home when they chose and were made to feel welcomed by the staff.” from the report
Medicines were not always safe
seriousSome medicines records contained gaps or errors. Guidance for medicines given when needed was not always available, and one medicine had not been accurately transferred from hospital information.
“People did not always receive their medicines as prescribed.” from the report
Medicines supply
seriousMedicines were not always ordered promptly enough to ensure people had a continuous supply.
“Medicines were not always ordered in a timely manner to ensure people had adequate and continual supply.” from the report
Checks did not find problems
seriousThe home's audits and quality checks had not identified or addressed the medicines problems found by inspectors.
“A quality assurance system was in place. This had not identified or addressed the discrepancies we saw in the handling and administration of medicine.” from the report
Communication with relatives
needs fixingCommunication and engagement were not always effective. Some relatives said they had to take the initiative to find out information.
“Communication isn't always good, I have to be proactive in finding out anything.” from the report
Mixed views on staffing
needs fixingStaffing looked adequate on the inspection day, but some relatives said there were not enough staff on some days and that people sometimes waited for help.
“Sometimes they could do with more staff. [Family member] sometimes has to wait for the toilet.” from the report
- 01What specific changes have been made to medicine administration records and checks since the inspection?
- 02How do you make sure medicines are ordered in time and people have a continuous supply?
- 03How are staff given clear written guidance for medicines prescribed to be given when needed?
- 04What has been done to improve communication with relatives?
- 05How do you check that staffing levels are enough on days when relatives have reported delays?
This was a focused inspection of Safe and Well-led only; the other question ratings were carried forward from the previous inspection published on 13 September 2019. This explanation was written from the published report of 1 September 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, February 2022
Inspected but not rated; inspectors found several good infection-control arrangements but also areas needing improvement.
This was an announced, targeted inspection on 10 January 2022. It followed concerns about infection prevention and control, and also looked at staffing pressures linked to COVID-19.
Inspectors found good arrangements for visits, testing, social distancing, admissions and separating people during an outbreak. Relatives were kept informed, and staff used practical ways to support communication and wellbeing.
However, the staff preparation and break room was not clean or fully stocked. Inspectors also found concerns with some flooring, baths, sinks, limescale and the storage of personal toiletries. Some policies were out of date or did not match what the home was doing.
The service was inspected but not rated. This was not a full assessment of the home, so it does not give an overall Good, Requires Improvement or Inadequate rating.
Safe visiting
The home had a heated visiting pod with a screen and intercom, allowing visits throughout the year and during an outbreak.
“The home had a purpose-built visiting pod in the garden which had a substantial screen, intercom and heating.” from the report
Outbreak arrangements
The layout could be changed to support COVID-19 guidance. Areas could be separated, with staff working in specific areas without mixing.
“Areas were able to be split up and people who used the service segregated when there was an outbreak, with staff working within the specific areas and not mixing.” from the report
Family communication
Relatives said they were kept informed about changes to guidance. The home used video meetings and a private social media page to share pictures.
“Relatives said the management and staff have been very good at keeping them informed of changes to guidance in a timely manner.” from the report
Infection-control checks
Inspectors were assured that several important arrangements were in place, including testing, safe admissions and support for visits.
“We were assured that the provider was accessing testing for people using the service and staff.” from the report
Staff preparation room
needs fixingThe room used for staff preparation, breaks and putting on or removing protective equipment was not clean or fully stocked. Inspectors said this could affect infection control.
“The room for staff to prepare for work and take breaks in, including donning and doffing personal protective equipment (PPE), were not kept to a clean standard or fully stocked which could impact on their ability to stop the spread of infection.” from the report
Environment and toiletries
needs fixingSome areas needed improvement, including damaged flooring, baths, sinks, limescale and the management of residents' personal toiletries.
“The environment and practice in certain areas needed to be improved as risks were posed to infection control and prevention.” from the report
Out-of-date policies
needs fixingSome policies did not reflect current government guidance, other policies or the home's actual practice. Inspectors said this could confuse staff.
“The policies and procedures in place were not all up to date with Government guidance, or reflected the existence of the provider's other policies, or covered what the home was actually doing.” from the report
- 01What has been changed in the staff preparation and break room, and how do you check that it remains clean and fully stocked?
- 02Have the damaged flooring, baths, sinks and limescale been repaired or cleaned, and when were these actions completed?
- 03How are residents' personal toiletries now managed to reduce infection-control risks?
- 04Which infection-control policies were updated after the inspection, and how do you make sure staff follow the current versions?
- 05How are COVID-19 staffing pressures currently affecting staffing levels and care?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; the service was inspected but not rated and the other questions were not assessed. This explanation was written from the published report of 11 February 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 Overbury House Nursing and Residential Home
7 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- September 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Overbury House Nursing and Residential Home →
- February 2022Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Overbury House Nursing and Residential Home →
- January 2021Inspected but not ratedSafe: Inspected but not rated
- September 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- January 2019Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2018Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2018Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 December 2010.
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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