CQC report explained · a nursing home
What the CQC found at QEF Care and Rehabilitation Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were supported safely with risks, medicines, staffing and infection control. Staff knew how to recognise and report abuse or neglect.
- Effective?
- Good
- Care and therapy were planned around each person’s needs and delivered with input from health and social care professionals. Staff received training and people could access healthcare support.
- Caring?
- Good
- People said staff were kind, respectful and listened to them. Care plans supported people’s dignity, comfort, choices and independence.
- Responsive?
- Good
- Care, therapy and activities were personalised. People were supported with communication, relationships, interests, visits and complaints.
- Well-led?
- Requires improvement
- Managers had identified improvements and completed some urgent safety actions, but oversight was not always consistent. Some actions were not completed promptly or recorded as completed.
What inspectors found, October 2021
Rated Good overall; inspectors found safe, kind and personalised care, but the home’s leadership and improvement monitoring required improvement.
This was the home’s first inspection since registration. It was unannounced and took place on 2 September 2021. Inspectors spoke with people, relatives and staff, and reviewed care, medicines, staffing, training, complaints and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found enough staff, safe medicines support, suitable infection controls and care tailored to people’s rehabilitation goals. People were supported to regain independence and to take part in activities.
Well-led was rated Requires Improvement. The home had made several changes and had completed some urgent safety actions, but it had not yet consistently brought improvement actions together, completed them on time or shown that changes were fully embedded.
The overall rating was Good. The report says CQC will continue to monitor information about the home and check whether quality and safety monitoring has become consistent at the next inspection.
Safe support
Inspectors found that people received safe support with their health, physical and emotional needs, medicines and risks.
“People received safe support around their health, physical and emotional needs and medicines.” from the report
Joined-up rehabilitation
The home worked with NHS and other professionals so that care and therapy could be adjusted to people’s individual goals.
“People received personalised care with support being provided in a targeted, joined-up way by different health and social care professionals.” from the report
Kind and respectful care
People were treated with kindness and dignity. Staff encouraged people to do what they could for themselves.
“People were supported to regain their independence and to remain comfortable.” from the report
Activities and communication
People had access to communication aids, therapy and activities linked to their interests and rehabilitation.
“The centre ran Choices project around activities which enabled people to develop their skills.” from the report
Improvement actions not consistently tracked
needs fixingManagers did not always ensure that actions from audits were added to the improvement plan and completed promptly. Some changes, including improvements to induction records, had not been signed off as complete.
“However, not all actions identified for completion were always consolidated into the service improvement plan and completed as promptly as possible.” from the report
- 01Which actions from the July 2021 health and safety audit are still outstanding, and when were they completed?
- 02Have induction plans and records for new and agency staff now been completed and signed off?
- 03How do managers make sure therapy recommendations are followed consistently by all teams?
- 04How many agency staff are currently being used, and what progress has been made in recruiting permanent staff?
- 05How will you show that the service improvement plan is being reviewed and completed on time?
This was the home’s first unannounced inspection and covered all five CQC questions, including infection prevention and control, the premises and the care provided. This explanation was written from the published report of 8 October 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, May 2021
Targeted infection-control inspection; the home was not rated overall, with strong COVID-19 precautions but incomplete cleaning records.
This was an announced, targeted inspection of infection prevention and control during the COVID-19 pandemic. The report says the inspection took place on 7 April 2021, although the front page gives 08 April 2021.
Inspectors were assured about visitor screening, testing, personal protective equipment, isolation arrangements, social distancing and the home's infection-control policy. People isolating in their rooms were supported with activities and suitable equipment.
The building appeared clean and hygienic. However, housekeeping staff were not on duty every day because of staff shortages, and there were no records showing communal areas had been cleaned on those days. The home put suitable recording in place during the inspection.
The service was inspected but not rated. This report does not give an overall quality rating or ratings for most of the five key questions.
Visitor infection controls
Visitors were screened for COVID-19 symptoms and had to complete a lateral flow test before entering, in line with government guidance at the time.
“All visitors were screened for symptoms of COVID-19 before being allowed to enter the home” from the report
PPE and outbreak planning
The home had a separate area and staffing plan for a possible COVID-19 outbreak. Inspectors also saw staff using PPE properly.
“We saw good PPE practice from staff during the inspection.” from the report
Support during isolation
People isolating in their rooms were given regular support to take part in activities they chose, with equipment provided to help.
“People who had to isolate in their rooms received frequent support from staff to engage with activities of their choice” from the report
Cleaning records
needs fixingHousekeeping staff were only on duty six days a week because of staff shortages. There were no records showing communal areas had been cleaned on the other days, although suitable recording was put in place during the inspection.
“there were no records of cleaning of communal areas being carried out on the days when housekeeping staff were not on duty.” from the report
- 01How is cleaning of communal areas recorded on every day, including days when housekeeping staff are not on duty?
- 02Has the housekeeping staff shortage been resolved, and how many housekeeping staff are currently in post?
- 03What separate area and staffing arrangements are still in place if there is a COVID-19 outbreak?
- 04How are people supported with activities if they need to isolate in their rooms?
This was a targeted inspection of infection prevention and control during the COVID-19 pandemic; the service was inspected but not rated and the other key questions were not assessed. This explanation was written from the published report of 6 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.
Every inspection of QEF Care and Rehabilitation Centre
Each visit the CQC has published, newest first, back to the day the home was registered.
- October 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at QEF Care and Rehabilitation Centre →
- May 2021Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at QEF Care and Rehabilitation Centre →
- June 2020
Registered with the Care Quality Commission on 15 June 2020.
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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