CQC report explained · a nursing home
What the CQC found at Peacock Manor Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Inspectors found some areas were unclean, a medicines stock count was unclear, and some care and risk records were inconsistent. They also said renovation and maintenance were needed.
- Effective?
- Good
- People received support with food, drinks and healthcare, and staff had suitable training. The home was working within the principles of the Mental Capacity Act.
- Caring?
- Good
- Staff were patient, kind and respectful. People and relatives were involved in care decisions, and staff supported privacy, dignity and independence.
- Responsive?
- Good
- Care was personalised and people could make choices about meals, activities and how they spent their time. Complaints were investigated and end of life wishes were recorded.
- Well-led?
- Good
- Managers had improved audits, action plans and oversight. Staff said managers were approachable and felt supported in their roles.
What inspectors found, July 2022
Rated Good overall, but Safe Requires Improvement because inspectors found cleaning, medicines records and care records that needed improvement.
Inspectors visited without notice on 27 and 30 June 2022. They spoke with people, relatives, staff and managers. They reviewed care records, medicines records, staff files and quality checks.
People generally experienced kind and respectful care. Staff knew people well, supported their choices and helped with food, drinks, activities and relationships. The home had enough staff and staff had suitable training.
The main weaknesses were under Safe. Some areas were unclean, one medicines stock record was unclear, and some care and risk records were inconsistent. Renovation and maintenance were also still needed.
The overall rating improved from Requires Improvement to Good since the previous inspection. The home was no longer in breach of regulations, but Safe remained Requires Improvement, so the service was not consistently safe in every area.
Kind, respectful staff
People were treated with patience and kindness. Staff knew people well and supported their dignity and independence.
“People were supported by staff who knew them, who listened to their opinions and acted on them.” from the report
Good food and hydration support
People were offered meal choices, healthy food, drinks and snacks. Staff generally paid attention to people's needs at mealtimes.
“We saw a variety of drinks and snacks available throughout the day which included healthy options such as a fresh fruit prepared in easily manageable slices.” from the report
Improved management
The home had improved its audits and quality checks since the last inspection. Managers used action plans and staff meetings to respond to concerns and share learning.
“Audits were in place which had been developed to assess risk and quality.” from the report
Good involvement of families
Relatives were consulted about care plans and people's preferences. People and relatives could give feedback through meetings and questionnaires.
“Relatives had been consulted in the creating of the care records which helped in assessing people's needs and gave valuable insight into people's preferences.” from the report
Cleaning standards
needs fixingSome areas were not clean on the first day of inspection. The manager acted quickly, but inspectors asked the home to review its cleaning standards.
“Areas of the service were found to be unclean on the first day of inspection however this was quickly addressed by the registered manager.” from the report
Care and risk records
needs fixingSome care plans and safety records did not contain consistent or complete information about people's needs and monitoring.
“Care plans had been developed which assessed the risks to people however some information was inconsistent, and some areas would benefit from expansion to fully consider and explain people's care needs.” from the report
Medicines stock records
needs fixingThere was confusion about the stock count for one medicine. The medicine was available and the person was not affected, but the recording process needed to improve.
“On the day of the inspection there was some confusion regarding the stock count of one medication however this was quickly resolved.” from the report
Renovation and maintenance
minorInspectors found that the premises needed renovation and maintenance. The provider had an ongoing renovation plan, but some work had been delayed.
“The premises need renovation and maintenance which had been delayed due to Covid-19 restrictions.” from the report
- 01What cleaning checks are now in place, and how do you make sure standards stay consistent across both wings?
- 02How do you check medicines stock records so that counts and receipts are accurate?
- 03How have you updated care and risk records to make sure information about each person's needs is complete and consistent?
- 04Which renovation and maintenance work has been completed, and what remains outstanding?
- 05How are relatives involved in reviewing care plans and people's changing preferences?
This inspection covered the five key questions and infection prevention and control, and checked the action plan following breaches found at the previous inspection. This explanation was written from the published report of 22 July 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, July 2021
Rated Requires Improvement; inspectors found infection control and management oversight failures, although staffing and medicines support were generally safe.
This was an unannounced focused inspection on 17 May 2021. Inspectors checked whether the home had acted on its previous improvement plan. They looked at Safe, Effective and Well-led. They spoke with people, relatives and staff, and reviewed care, medicine, recruitment and management records.
The home did not always protect people from infection. Staff did not always use or change protective equipment correctly. Some visitors were not screened properly, and some staff worked in different care settings. Recruitment checks were incomplete, and audits did not identify important problems.
People did not always receive enough choice about meals or how they wanted to be cared for. Records about people's wishes and legal restrictions were not always complete. However, there were enough staff, medicines were usually given correctly, and staff worked with health professionals.
The overall rating stayed at Requires Improvement. The home had also been rated Requires Improvement at the previous inspection, and had held Requires Improvement or Inadequate ratings for four consecutive inspections. The provider remained in breach of legal requirements.
Enough staff
Inspectors found there were enough staff to meet people's needs and that staffing was reviewed according to the care required.
“There were enough staff to meet the needs of people living at the service as staff were deployed throughout the two wings of the service.” from the report
Medicines usually given safely
Staff had regular competency checks and inspectors observed medicines being given at the correct time and as prescribed.
“We observed medication given at the correct time and in line with the prescribed instructions.” from the report
Health professional support
Staff worked with health and social care professionals to support people's health and wellbeing.
“Staff worked with other agencies to support people to access health and social care professionals to live a healthy life.” from the report
Improved premises
The premises had been renovated since the previous inspection. Inspectors said the changes helped people living with dementia move around and take part in reminiscence activities.
“The provider had renovated the premises since the last inspection and staff spoke positively of about the changes.” from the report
Infection control
seriousPeople were exposed to avoidable infection risks because PPE was not always used or changed correctly. Visitor screening and the policy on staff working across services were also inadequate.
“Staff did not wear or change PPE to effectively to protect people from the risk of infection transmission.” from the report
Weak management checks
seriousThe home's audits failed to identify several problems found by inspectors. The provider was in breach of the governance regulation.
“The registered manager had failed to ensure robust assurance and auditing processes to assess, monitor and drive improvement in the quality and safety of the services provided.” from the report
Limited choice at mealtimes
needs fixingPeople were not always told accurately what food was available and were not actively offered alternatives. Extra portions could depend on staff availability and initiative.
“The provider did not actively offer people alternative food choices, such as vegetarian options.” from the report
Incomplete recruitment checks
needs fixingSome staff had been recruited without a full employment history being obtained. This meant recruitment was not always safe.
“The provider had recruited some staff without having obtained their full employment history.” from the report
Incident learning
needs fixingThe manager had not reviewed patterns or trends from incidents, so staff did not consistently learn how to prevent similar injuries or other problems happening again.
“The registered manager had not reviewed patterns or trends from incidents, to share learning with staff and minimise the risks to people.” from the report
- 01What has changed to make sure staff use and change PPE correctly every time?
- 02How are visitors now screened for COVID-19 risks, and how do you manage staff who work at other care settings?
- 03How do you make sure people are offered accurate meal information, alternatives and extra portions when wanted?
- 04How have you improved recruitment checks, staff training and audits since this inspection?
- 05How do you now review incidents and share learning to prevent similar injuries or problems happening again?
This was a focused inspection of Safe, Effective and Well-led; the other question ratings were not assessed and the previous ratings were carried forward into the overall rating. This explanation was written from the published report of 22 July 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 Peacock Manor Nursing Home
6 rated inspections over 4 years: the service has improved, from Inadequate to Good.
- July 2022Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2021Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- March 2020Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2019Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2019Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2018InadequateSafe: Requires improvementEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2017
Registered with the Care Quality Commission on 21 July 2017.
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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These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,010 to £1,290 a week. 27 can care for a couple. 12 years' experience on average.
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