CQC report explained · a nursing home
What the CQC found at Red Court Care Community
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments and care plans did not contain enough information, and incidents were not always recorded or properly followed up. Medicines, staffing, infection control and visiting arrangements were areas where inspectors found safer practice.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Quality monitoring did not identify or address problems in care records, incident reporting and person-centred care. Leadership and management oversight remained inconsistent.
What inspectors found, August 2022
Red Court Care Community was rated Requires Improvement; inspectors found poor risk management, safeguarding records and quality oversight.
This was an unannounced follow-up inspection on 27 and 29 June 2022. Inspectors spoke with people, staff and relatives, and reviewed care records, medicines records, staff files and management records. Infection prevention and control was also checked.
The home had not always assessed risks properly or updated care plans when people's needs or the environment changed. Incidents were not always reported, including repeated attempts by some people to leave the building. Inspectors also found that a safeguarding concern had not been reported to the local safeguarding team until they prompted the manager.
There were some improvements. Medicines were administered safely, staffing levels had improved, and changes to the environment had created a calmer setting for people living with dementia. However, the home remained in breach of regulations and was rated Requires Improvement overall, as well as Requires Improvement for Safe and Well-led.
Safer medicines practice
Inspectors found improvements in medicines management. Medicines were administered safely and controlled drugs were managed safely.
“Staff undertook safe practices when administering medicines. Storage and management of controlled drugs was safely managed.” from the report
Improved staffing
Staffing levels and deployment had improved since the previous inspection. Inspectors found there were enough staff to support people.
“At this inspection we saw the changes the provider had made had improved the deployment of staff and impacted positively on the care people received.” from the report
Calmer environment
Changes to the environment had made the setting calmer and had benefited people living with dementia.
“This had resulted in a calmer environment and supported people living with dementia.” from the report
Mental capacity practice
The home was working within the principles of the Mental Capacity Act. Required authorisations and their conditions were in place where needed.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place” from the report
Risk records were incomplete
seriousRisks were not always properly assessed, and care plans were not updated when people's needs or the environment changed. This increased the risk of harm, including during an emergency evacuation.
“The risks to people's safety were not robustly assessed. Risk assessments and care plans did not contain enough information about people's needs.” from the report
Incidents and safeguarding
seriousIncidents were not always recorded or reviewed, including more than 35 reported occasions of people trying to leave unsupervised. A safeguarding concern was not reported to the local safeguarding team until inspectors prompted the manager.
“Incidents were not always recorded on the provider's incident reporting systems by staff resulting in the provider not having effective oversight of incidences and how they could work to reduce them.” from the report
Weak quality oversight
needs fixingAudits did not reliably identify problems in care records, incident reporting or the dining experience. Inspectors found that care was not always person-centred and staff could be task-focused.
“The provider failed to ensure systems were in place to ensure people received person-centred care and the quality of care improved.” from the report
- 01How are you now assessing and updating risks when a person's needs or room changes?
- 02How do you record and review attempts by people to leave the building unsupervised?
- 03How are safeguarding concerns identified, recorded and reported to the local safeguarding team?
- 04What checks now make sure care plans and incident records are accurate and up to date?
- 05What action has been taken to make mealtimes more organised and person-centred?
This was a focused follow-up inspection of Safe and Well-led, with infection prevention and control also checked; the other key-question ratings were carried over from the previous inspection. This explanation was written from the published report of 10 August 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 2022
Rated Requires Improvement; inspectors found unsafe staffing, medicine and risk-control problems, with weak management oversight.
This was an unannounced inspection over three visits in February 2022. Three inspectors spoke with people, relatives and staff, and reviewed care records, medicines records, audits and infection-control documents.
The inspectors found that some care risks were not managed as recorded. Bed rails and safety equipment were not always used correctly. Staffing was not enough for people living with dementia, which caused delays and left some people without support. Medicines were not always stored or managed safely, and infection-control and kitchen-cleanliness problems were found.
People said they felt safe and described staff as kind and friendly. There were activities, safe recruitment checks and opportunities for people and staff to give feedback. However, management checks did not identify important problems, and lessons from incidents were not consistently recorded or shared.
The overall rating was Requires Improvement. Safe and Well-led were both rated Requires Improvement. This was the same overall and key-question rating as the previous inspection, and the service had held Requires Improvement for three consecutive inspections.
People felt safe
People and relatives told inspectors they felt safe. They also described staff as kind and friendly.
“People living at the service told us they felt safe and were cared for by kind and friendly staff.” from the report
Activities
People had access to a range of activities, and inspectors saw several people taking part.
“People at the service had access to a wide range of activities.” from the report
Recruitment checks
The home used safer recruitment checks, including DBS checks.
“Safe recruitment processes were in place including the use of Disclosure and Barring Service (DBS) checks” from the report
People could give feedback
Residents' meetings and staff meetings gave people opportunities to comment on care and how the home was run.
“The service held regular residents meeting where people were able to give feedback about their care and the way in which the home is run.” from the report
Risk controls were not followed
seriousInspectors found that bed-rail precautions and sensor-mat checks were not always followed. This created a risk of falls or entrapment.
“The registered manager and the provider had failed to ensure people were protected from the risk of harm associated with their care.” from the report
Not enough staff
seriousStaffing was not sufficient for the needs of people living with dementia. Some people waited for care, and others could be left without supervision when staff were helping someone else.
“Staffing levels were not sufficient to meet the needs of the people using the service, placing them at risk of harm.” from the report
Medicine safety
seriousMedicines were not always stored or administered safely. Discarded medicines were found in an unlocked communal room, and controlled-medicine stock checks were not done as planned.
“Medicines were not always stored and administered safely.” from the report
Infection and cleanliness problems
needs fixingParts of the kitchen were unclean or damaged, some food was not dated or covered, and staff did not always follow mask and laundry procedures.
“Areas of the kitchen including cookers were unclean.” from the report
Weak management oversight
seriousQuality audits did not identify problems before the inspection. Incidents were not always recorded, analysed for patterns or used to share learning with staff.
“The provider had failed to ensure that systems and processes were in place to drive quality and improvements.” from the report
- 01How many staff are now allocated to each dementia wing during the day and at night, and how is this matched to residents' current needs?
- 02How do you check that bed rails, bumpers and sensor mats are correctly in place for each person who needs them?
- 03How are medicines stored, discarded and counted, including controlled medicines, and how often are these checks completed?
- 04What changes have been made to kitchen cleanliness, food labelling, laundry separation and staff mask use?
- 05What has changed in the quality-audit and incident-reporting systems since the warning notice, and can you show families the results?
This was a focused inspection prompted by infection-control concerns and widened to Safe and Well-led; the other key-question ratings carried over from the previous inspection. This explanation was written from the published report of 31 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.
Every inspection of Red Court Care Community
6 rated inspections over 3 years: the service has improved, from Inadequate to Requires improvement.
- August 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- April 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Inadequate
- August 2019Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- March 2019InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- September 2017
Registered with the Care Quality Commission on 12 September 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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9 live-in carers within about an hour of Lincolnshire
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.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.