CQC report explained · a nursing home
What the CQC found at Roden Hall Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about visitor controls, testing, personal protective equipment, social distancing, cleaning and infection outbreak arrangements. They were not assured that the proposed additional beds could safely separate people with COVID-19 from other residents.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, March 2021
Inspected but not rated; inspectors found strong infection control arrangements but were not assured that the proposed extra beds could safely separate people with COVID-19 from other residents.
This was an announced, targeted inspection on 22 January 2021. It focused on infection prevention and control in an extension to the home's designated unit for people discharged from hospital with COVID-19.
Inspectors found good arrangements for visitors, testing, personal protective equipment, cleaning, social distancing and staff risk assessments. They were also assured that people were being admitted safely and that infection outbreaks could be prevented or managed.
However, inspectors were not assured that the proposed additional beds were ready to safely separate people who had tested positive for COVID-19 from residents who had not. The service was inspected but not rated, so this report does not give an overall quality rating.
Clean proposed unit
The proposed extension was clean and uncluttered. Cleaning schedules were in place and checked by the registered manager.
“The proposed extension to the designated unit was clean, hygienic and uncluttered.” from the report
Visitor safety
Visitors had to complete COVID-19 screening, have their temperature checked and wear protective equipment. Risk assessments were used for exceptional visits.
“Visitors were required to complete a COVID-19 screening questionnaire, temperature checks were undertaken prior to entry and they were required to wear Personal Protective Equipment (PPE) in line with current guidance.” from the report
Staff infection control
Staff had infection prevention and control training and used protective equipment in line with guidance.
“People were supported by staff who were trained in infection prevention and control (IPC) and wore PPE in line with current guidance.” from the report
Staff risk assessments
The provider assessed staff members' infection risks and put measures in place where higher risks were identified.
“Staff risk assessments were undertaken and where staff were identified as being at higher risk of infection, measures were put in place to mitigate the risks.” from the report
Separation of residents
seriousThe proposed extra beds were not ready to ensure people who had tested positive for COVID-19 would be kept separately from residents who had not tested positive. This could affect infection control if the beds were used before the arrangements were ready.
“We were not assured that the additional beds proposed met good infection prevention and control guidelines specifically as a designated care setting.” from the report
- 01Are the proposed additional beds now arranged so that people who test positive for COVID-19 can be kept separate from other residents?
- 02How do you manage admissions of people discharged from hospital with a positive COVID-19 status?
- 03How are cleaning schedules checked, and how often are they reviewed?
- 04What current rules apply to visitors, including screening, temperature checks and protective equipment?
- 05How do you identify and reduce infection risks for staff who may be at higher risk?
This was a targeted inspection of infection prevention and control in the proposed extension to the designated unit; the service was inspected but not rated and the wider quality of care was not assessed. This explanation was written from the published report of 5 March 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, December 2020
Inspected but not rated; inspectors found good infection control arrangements in the designated unit.
This was an announced inspection on 3 and 9 December 2020. Inspectors visited the part of the home being prepared as a designated care setting for people discharged from hospital with a positive Covid-19 status.
They looked at infection prevention and control. They found a separate area, separate entry, en-suite facilities and a staff team working only on that unit. Staff used personal protective equipment and had infection control training.
The unit appeared clean and hygienic. Cleaning checks, infection control audits, testing, risk assessments and ways for residents to contact relatives were in place. The service was inspected but not rated, so this report does not provide a full quality rating for the home.
Separate Covid-19 area
The designated unit was self-contained, with its own entrance and en-suite facilities. Staff worked only on this unit to reduce the risk of infection spreading.
“People residing on the unit identified for the designated care setting were supported in a self-contained area of the home that was accessed via a separate entry.” from the report
Protective equipment
Staff had infection control training and used protective equipment in line with the guidance in place at the time.
“People were supported by staff who were trained in infection prevention and control (IPC) and wore Personal Protective Equipment (PPE) in line with current guidance.” from the report
Clean surroundings
Inspectors found the designated area clean and hygienic. Cleaning schedules and daily checks were being used.
“The designated care setting appeared clean and hygienic. Cleaning schedules were in place and daily checks were undertaken to monitor cleanliness” from the report
Contact with relatives
Residents could communicate with relatives by telephone and video calls. Window visits were also planned.
“People were supported to communicate with their relatives via telephone and video calls.” from the report
Inspectors raised no specific concerns in this report.
- 01Would my relative live in the designated unit that inspectors visited, or in another part of the home?
- 02Are staff still working solely on the designated unit, or have staffing arrangements changed?
- 03How are visitors, testing and protective equipment managed now?
- 04How often are infection control checks and audits carried out, and how are any actions followed up?
- 05What current inspection information is available for care, medicines, staffing and management, which this inspection did not assess?
This was a focused inspection of infection prevention and control in the designated unit only; inspectors did not look at the whole home and the service was not rated. This explanation was written from the published report of 22 December 2020 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 Roden Hall Nursing Home
4 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- December 2020Inspected but not ratedSafe: Inspected but not rated
- December 2020Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- March 2019Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2016
Registered with the Care Quality Commission on 6 June 2016.
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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