CQC report explained · a nursing home
What the CQC found at Paisley Court
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2022
Rated Requires Improvement; inspectors found caring staff, but safety, cleanliness, medicines records and management checks needed improvement.
This was an unannounced focused inspection over three days. Inspectors spoke with people, relatives, staff and a visiting professional. They observed care and reviewed care plans, medicine records, staff files and management records.
The home was not always clean, secure or well maintained. Inspectors found problems with bathrooms, storage, locks, damaged equipment and records for creams, thickening products and fluid intake. Some risk assessments and care plans did not contain enough detail.
Staff were caring and knew people well. People were protected from abuse, recruitment checks were completed and most staffing levels were maintained. However, staff deployment at busy times needed review. The overall rating changed from Good at the previous inspection to Requires Improvement.
Caring relationships
Inspectors saw positive interactions. Staff knew people well and relatives spoke positively about the care.
“We observed people supported by staff who knew them well.” from the report
Protection from abuse
Staff had safeguarding training and knew how to raise concerns. Safeguarding referrals and investigations were recorded.
“People were protected from the risk of abuse; policies and procedures supported this.” from the report
Recruitment checks
Checks were completed before permanent and temporary staff worked with people.
“Appropriate checks had been made before being offered employment.” from the report
Partnership working
The home worked with external professionals and held meetings with relatives to gather views and share information.
“The team are very engaging. It feels like all the staff have our patients interests at heart and know people well.” from the report
Cleanliness and security
seriousSome areas were dirty or unhygienic. Broken locks, unsafe storage, damaged equipment and inaccessible bathrooms created safety risks.
“Areas of the service were not sufficiently clean.” from the report
Medicines and risk records
seriousRecords for prescribed creams and thickening products were incomplete or inconsistent. Fluid totals and some risk assessments were also not reliable enough.
“This meant we were not assured people were receiving all their medicines as prescribed.” from the report
Weak management checks
seriousAudits had not reliably found or resolved problems. A previous mock inspection had identified several issues, but progress was limited.
“Checks made by the management team had not always identified the areas for improvement we found during this inspection.” from the report
Staff deployment
needs fixingStaffing levels were usually maintained, but inspectors saw short periods without staff support in communal areas. Staff said more help was needed at busy times.
“We recommend the registered manager reviews current arrangements to deploy staff effectively across the service.” from the report
Dementia support
needs fixingSome areas were locked for everyone rather than managed according to individual needs. There was also little signage to help people living with dementia find their way around.
“There was also a lack of direction signage evident to support people who lived with dementia to orientate around their home environment.” from the report
- 01What has been done to deep-clean the kitchen, dining areas and bathrooms, and how is cleanliness now checked?
- 02How are medicines records for creams and thickening products being checked to make sure they match prescriber instructions?
- 03How are care plans, risk assessments and fluid records now reviewed by the nursing team?
- 04What changes have been made to staff deployment during busy times such as mornings and bedtime?
- 05How have the environment and signage been changed to better support people living with dementia?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection, whose rating was published on 11 January 2018. This explanation was written from the published report of 19 November 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, February 2022
Paisley Court was inspected but not rated; inspectors found safe infection control and visiting arrangements during the COVID-19 response.
This was an announced, targeted inspection on 25 January 2022. Inspectors looked mainly at infection prevention and control, including visiting, protective equipment, testing, cleanliness and vaccination requirements. They also asked about staffing pressures linked to COVID-19.
Inspectors found safe systems for visits. Staff used and disposed of protective equipment safely, people and staff were tested regularly, and the home was clean and hygienic. They were assured that the home had measures to prevent and manage infection outbreaks.
The service was inspected but not rated. This means the report does not give a Good, Requires improvement or Inadequate rating for the service or for Safe.
Safe visiting
The home had systems to support visits in line with national guidance.
“The provider had safe systems in place to facilitate and support visiting at the home in line with the national guidance.” from the report
Use of PPE
Staff used, removed and disposed of protective equipment safely and wore the required levels during the inspection.
“Staff donned, doffed and disposed of personal protective equipment (PPE) safely and in line with the relevant guidance.” from the report
Regular testing
People living in the home and staff were tested regularly in line with national guidance.
“Staff and people living at the home were tested regularly for COVID-19 in line with the national guidance.” from the report
Clean environment
Inspectors found the home clean and hygienic, with frequent cleaning during the day.
“The home was clean and hygienic. Frequent cleaning was carried out throughout the day ensuring good standards of hygiene and cleanliness were maintained.” from the report
Infection control systems
Inspectors were assured about the arrangements for preventing, identifying and managing infections, including the vaccination requirements for staff and visiting professionals.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Inspectors raised no specific concerns in this report.
- 01What measures are currently in place to manage COVID-19-related staffing pressures, and how have these affected care?
- 02How are visits supported if there is an infection outbreak or increased infection risk?
- 03How often are people living in the home and staff tested, and how are positive results managed?
- 04How do you check that staff and visiting professionals meet the COVID-19 vaccination requirements or have an exemption?
- 05How often are shared areas and frequently touched surfaces cleaned during the day?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; it did not provide ratings for the other key questions. This explanation was written from the published report of 15 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 Paisley Court
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- November 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- January 2018Goodstayed GoodSafe: GoodWell-led: Good
- April 2017GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 January 2011.
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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