CQC report explained · a nursing home
What the CQC found at Premier Court Care 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
- Inspectors found better risk checks and enough staff, but some infection control practices were not followed consistently. The medicines room was cramped and cluttered, and inspectors said there was limited assurance about safety.
- Effective?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- This question was not assessed during this focused inspection. Inspectors did record that people and relatives praised staff for being kind and caring.
- Responsive?
- Good
- This question was not assessed during this focused inspection. The report says some relatives felt communication had declined, while others reported good communication.
- Well-led?
- Requires improvement
- Quality monitoring was not used effectively to drive improvements. Management instability over two years had affected staff morale, confidence and trust.
What inspectors found, May 2021
Rated Requires Improvement; safety had improved since the last inspection, but weak monitoring and management instability led to a Regulation 17 breach.
This was an unannounced focused inspection on 19 April 2021. One inspector checked whether the home had followed its previous action plan and looked mainly at Safe and Well-led. Infection control was also checked because of COVID-19 risks.
Inspectors found improvements in safety since the previous inspection. There were checks for risks such as pressure damage, choking, oxygen use and fire safety. People appeared safe and contented, and relatives praised staff for being kind. However, infection control checks at the entrance were not always completed, social distancing was not always followed, and the medicines room was cramped and cluttered.
The home was still not well-led. Quality checks had not led to action on some problems, including damaged bathroom tiles and staff survey concerns. There had also been four managers in two years, which staff said had damaged morale and trust.
The overall rating remained Requires Improvement. Safe and Well-led were both rated Requires Improvement. The home was no longer in breach of Regulation 12, but inspectors found a new breach of Regulation 17 about quality monitoring and governance.
Improved risk management
The home had clearer assessments and guidance for risks including oxygen use, choking, bedrails and fire evacuation. The previous breach relating to safe care and treatment had been resolved.
“People had individual risk assessments and staff demonstrated awareness of people's individual risks.” from the report
Kind and timely care
Inspectors found enough staff to meet people's needs in a timely way. Staff were described as professional and kind, and relatives said people were well looked after.
“The atmosphere in the home was calm with staff going about their duties professionally and with kindness.” from the report
Safeguarding arrangements
Staff had safeguarding training and knew how to report concerns. Incidents were reported to outside agencies when necessary.
“Safeguarding incidents were appropriately reported to external agencies when needed.” from the report
Several infection controls were in place
Inspectors were assured about safe admissions, use of protective equipment, testing, hygiene, outbreak management and the infection control policy.
“We were assured that the provider was using personal protective equipment (PPE) effectively and safely.” from the report
Weak quality monitoring
seriousThe home's governance systems did not reliably identify problems or make sure they were fixed. This was the reason for the Regulation 17 breach.
“The provider's governance systems were not effectively used to ensure the quality and the safety of the care people received was monitored and improved.” from the report
Management instability and low morale
needs fixingThere had been four managers in two years. Staff said this had reduced their confidence, trust and morale, and some relatives reported poorer communication.
“The service has experienced instability at manager level for the past two years.” from the report
Problems not acted on
needs fixingA bathroom had damaged tiles that had been present for months, but the issue was only added to the improvement plan after the inspection. Staff survey concerns had also not been acted on at the time of the visit.
“This shortfall was only added to the home's quality improvement plan after our visit as being a concern identified during inspection.” from the report
Inconsistent infection control at entry
needs fixingThe inspector's temperature was not checked and a health declaration was not requested before entry. Staff also did not always keep their distance from each other or outside professionals.
“However, despite prompting, the inspector's temperature was not checked and they were not asked to complete a health declaration before entering the home.” from the report
Cramped medicines room
needs fixingMedicines were stored securely, but the clinical room was cluttered and had little safe working space. Effective cleaning of the room was not possible.
“However, the clinical room was cramped and cluttered with little space to work safely and it was not possible to maintain effective cleaning of this space.” from the report
- 01Who is now the registered manager, and how long has the current management team been in place?
- 02How are staff survey concerns, including concerns about staffing, burnout, training and management, being acted on and checked?
- 03Has the damaged bathroom been repaired, and how do you make sure environmental problems are not left unresolved?
- 04What checks now make sure visitors have their temperature taken and complete a health declaration before entering?
- 05How has the clinical room been decluttered and arranged so medicines can be handled and the room cleaned safely?
This was a focused inspection of Safe and Well-led, including infection control; the other three question ratings were not assessed and previous ratings were carried forward. This explanation was written from the published report of 20 May 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.
What inspectors found, November 2019
Requires Improvement; inspectors found kind, effective care, but safety checks and management oversight were not reliable.
This was an unannounced inspection on 15 October 2019. One inspector and an Expert by Experience spoke with people, relatives, staff and managers. They observed care and reviewed care, medicines, recruitment and management records.
People were generally happy with their care. Staff were described as kind, attentive, trained and supportive. The home provided good care in the effective, caring and responsive areas.
There were important gaps in safety checks and risk assessments. These included oxygen, choking, pressure mattresses and unexplained injuries. Records about food and fluids were also not always complete.
The overall rating was Requires Improvement. The safe and well-led ratings fell from Good at the previous inspection. The provider was asked for an action plan, and CQC said it would continue to monitor the home.
Kind and respectful staff
People and relatives spoke positively about staff. Inspectors saw staff providing attentive and reassuring care.
“People told us that staff were kind and respectful.” from the report
Staff training and support
Staff had training relevant to their roles and said they felt equipped and supported.
“Staff had received training in subjects relevant to their role and they told us they felt equipped for their role.” from the report
Good access to healthcare
People had regular access to health and social care professionals, with referrals made when specialist help was needed.
“People had regular access to health and social care professionals.” from the report
Activities and community links
The home offered varied activities and links with local groups, including a nursery, school art class and book club.
“The home offered a room to use for groups in the community, for example a book club.” from the report
Incomplete risk assessments
seriousSome important risks were not assessed or clearly explained to staff. This included oxygen use and choking risks.
“People did not always have their risks assessed and systems for monitoring and promoting safety were not always robust.” from the report
Safety checks missed problems
seriousA pressure-relieving mattress was set incorrectly, but the daily check did not identify this. Fire evacuation information also did not show that oxygen was in use.
“On the day of inspection they failed to identify and address that the mattress was set wrong.” from the report
Unexplained injuries
seriousSome bruises and skin tears were recorded as unexplained, but there was no completed internal investigation record.
“For some injuries such as bruises or skin tears which were recorded as unexplained, a record of an internal investigation was not completed.” from the report
Weak management oversight
needs fixingAudits had not found several of the problems identified by inspectors, including gaps in risk assessments and food and fluid records.
“However, the checks had not identified the issues found relating to pressure mattresses being checked, appropriate risk assessments in place and food and fluid records not being completed robustly.” from the report
More stimulation needed for people in bed
needs fixingActivities were available, but staff and relatives said people cared for in bed needed more time and stimulation in their rooms.
“Relatives also told us people in their rooms needed more time for stimulation.” from the report
End of life plans needed detail
needs fixingEnd of life plans recorded people's wishes but did not give enough guidance to staff in advance of the final stage of life.
“The care plans needed to include more detail to guide staff on how to support people.” from the report
- 01Have all residents who use oxygen now got a clear risk assessment, care plan and safe evacuation information?
- 02How are choking risks assessed after an incident, and how are staff told what support is needed?
- 03How do managers now check that pressure-relieving mattresses are set correctly every day?
- 04How are unexplained bruises and skin tears investigated and recorded?
- 05How will people who are nursed in bed receive regular activities and stimulation in their rooms?
This was an unannounced inspection covering all five CQC questions, and the safe and well-led ratings fell from Good at the previous inspection. This explanation was written from the published report of 9 November 2019 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 Premier Court Care Home
5 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- May 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- April 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015Inspected but not ratedSafe: Requires improvementResponsive: Requires improvement
- April 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 November 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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