CQC report explained · a nursing home
What the CQC found at Salt Hill Care Centre
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2023
Rated Requires Improvement; inspectors found progress since the previous inadequate rating, but risks, medicines, consent and management systems still need attention.
The unannounced inspection visit took place on 5 July 2023. Inspectors also interviewed staff by telephone later in July. They spoke with people, relatives and staff, and reviewed care plans, medicine records, recruitment files, training information and management records.
The home had improved from its previous inadequate rating and was no longer in special measures. Inspectors found enough staff, suitable staff training, clean premises, infection control and better person-centred information about people's life stories and preferences.
However, risk assessments did not always give staff clear instructions to prevent harm. Medicine records and some covert medicine decisions were not always safe or properly documented. Care plans did not always meet the needs of people with dementia, autism, learning disabilities or communication difficulties. Quality checks did not reliably find these problems.
The overall rating was Requires Improvement. Safe, Effective and Well-led were also rated Requires Improvement. The report identifies legal breaches and says the provider must send an action plan, with progress monitored by the CQC and local authority.
Progress since the last inspection
The home improved from an overall inadequate rating and was no longer in special measures. Inspectors found that several previous concerns had been addressed.
“During this inspection the provider demonstrated that improvements have been made.” from the report
Kind and patient staff
People and relatives described staff positively. Inspectors observed staff speaking courteously and respectfully while supporting people.
“People and relatives described staff as caring, compassionate, thoughtful, and patient.” from the report
Staffing and training
The home had recruited additional permanent staff and inspectors found enough staff to support people's welfare and safety. Staff had completed essential and specialist training.
“There were sufficient staff deployed to ensure people's welfare and safety.” from the report
Clean environment
The home was generally clean, with stocked protective equipment stations and clean communal areas, bathrooms and sluice rooms.
“Bathrooms, sluice rooms and communal areas were clean and tidy.” from the report
Food and drink
People were offered varied snacks and meals could be adapted to cultural, religious and personal preferences. Feedback was used to improve menu choices.
“Meals were adapted to meet people's cultural and religious needs and a 3-week rolling menu was displayed showing food that people liked.” from the report
Dementia-friendly changes
The home had made environmental changes, including different coloured corridors and doors, memory boxes and a sensory room to support people living with dementia.
“A memory sensory room was available for people living with dementia.” from the report
Unclear risk assessments
seriousSome falls and moving and handling assessments did not give staff clear, practical instructions. Records did not always show that planned checks had been completed.
“People were not always protected from avoidable harm.” from the report
Medicine records and decisions
seriousInstructions for medicines given when needed, creams and eye drops were not always legible or consistent. Some covert medicines were given without the full legal process being followed.
“There were still some unsafe medicines practices that placed people at potential risk of harm.” from the report
Care plans did not cover all needs
seriousPlans did not always explain how dementia or autism affected daily life, set goals for semi-independent people or describe how staff should respond to distress.
“The care and support needs of people living with dementia, autism and living semi-independent were not always met.” from the report
Communication support
seriousThe home did not consistently provide accessible information or record how to support people whose first language was not English. This could leave people isolated or unable to understand what was happening.
“People's communication needs were not always met.” from the report
Consent and best interests
seriousMental capacity assessments were not always specific to one decision and some best interests records lacked the required involvement from relevant people and professionals.
“The provider did not always work in accordance with the Mental Capacity Act 2005.” from the report
Weak quality checks
seriousAudits did not reliably identify problems in care plans, medicines, risk assessments or consent records. Some records were illegible or incomplete.
“The provider's system for auditing the service did not always identify when quality and safety was being compromised.” from the report
- 01What has changed in the falls risk assessments, and how do you check that staff are following the instructions?
- 02How do you make sure PRN and topical medicine instructions are legible, consistent with prescriptions and fully recorded?
- 03For people who lack capacity, how are decision-specific mental capacity assessments and best interests decisions completed and reviewed?
- 04How will you provide accessible communication support for autistic people, people with learning disabilities and people whose first language is not English?
- 05What evidence can you show that your new audits and improvement plans are now finding and fixing the problems identified in this report?
This was an unannounced full inspection covering the premises and care provided, with ratings given for Safe, Effective and Well-led; Caring and Responsive were not rated in the report. This explanation was written from the published report of 20 September 2023 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, October 2022
Rated Inadequate and placed in special measures; inspectors found serious risks in safety, medicines, staffing, infection control and leadership.
This was an unannounced focused inspection on 18 August 2022 and 1 September 2022. Inspectors spoke with people, relatives and staff, and reviewed care plans, medicines records, recruitment files, training records and management documents.
The home was rated Inadequate for Safe and Well-led, and Requires Improvement for Effective. Inspectors found unsafe risk management, delays in responding to call bells, unsafe medicines practices, poor cleanliness, gaps in staff training and weaknesses in consent and care planning.
The home had previously been rated Good in 2018. The inspection was widened because of concerns raised about another service run by the provider. Caring and Responsive were not inspected during this visit, so their previous ratings were used when calculating the overall rating.
The home was placed in special measures. The CQC said it would request an action plan, monitor progress with the provider and local authority, and usually re-inspect within six months.
Fire and water safety checks
Routine fire safety checks had been completed and the fire service had recorded an adequate level of safety. The home also had a plan for managing Legionella in the water system.
“Routine checks of fire safety were completed, and the fire service had inspected the service in 2022, documenting there was an 'adequate' level of safety.” from the report
Some healthcare access
A GP visited regularly and staff used out-of-hours healthcare services when needed. Other professionals were also involved, including dentists, podiatrists and occupational therapists.
“A GP visited regularly, and staff could record in advance of the GP rounds any people that needed assessment.” from the report
Some positive feedback
Some people and relatives said they felt safe and gave positive feedback about the care. Inspectors also saw some staff communicating kindly with people.
“People and relatives did provide positive feedback about the care and support received.” from the report
Correct use of protective equipment
Inspectors saw staff using face masks and other protective equipment correctly. The infection prevention and control policy was up to date.
“Staff were observed to use PPE correctly, including face masks. The provider's infection prevention and control policy was up to date.” from the report
People at risk from poor risk management
seriousSome risks, including falls and distressed behaviour, were not properly assessed or managed. Inspectors found a person at very high risk of falls without the equipment recommended in their assessment.
“We found several examples of people with identified risks, such as falling, with either no appropriate plans to mitigate those risks or with no risk assessments in place.” from the report
Unsafe medicines
seriousSome refrigerated medicines were outside the recommended temperature range. PRN medicines were not always recorded properly, and some medicines were administered in ways that did not follow the prescription or legal requirements.
“Medicine practices were not always safe as staff failed to follow the provider's medicines policy and procedures.” from the report
Insufficient staffing
seriousInspectors saw a person waiting several minutes for help to use the bathroom. Staffing levels did not always support people who needed close supervision or two staff for care.
“This meant people did not always get appropriate assistance when required to meet their needs.” from the report
Poor infection control and cleanliness
seriousInspectors found dirt, body fluid marks, poor separation of clean and dirty items, linen stored on the floor and cleaning methods that could spread bacteria and viruses.
“People were placed at risk of harm from infections, because hygiene standards were inadequate.” from the report
Incomplete staff training
seriousMany staff had not completed or renewed required training. The lowest completion rates were in areas including fire safety, moving and handling, medicines and falls prevention.
“Areas of high risk, such as fire safety, practical moving and handling, medicines management and falls prevention had the lowest completion rates.” from the report
Weak management oversight
seriousAudits failed to identify problems with care plans, medicines, staffing, training and risk management. Board-level quality meetings had stopped and records were sometimes illegible or incomplete.
“Quality assurance systems used to assess, monitor and improve service delivery were inadequate.” from the report
- 01What action have you taken to make sure falls risks, distressed behaviour and unexplained injuries are properly recorded, investigated and managed?
- 02How do you now check that medicines are stored at the correct temperature and that PRN and covert medicines are administered lawfully and recorded fully?
- 03What are the current staffing levels on each floor, and how do you make sure there are enough trained staff for people who need two staff or close supervision?
- 04Which staff training was incomplete at the inspection, and can you show that training and competency checks have now been completed?
- 05What improvements have been made to cleanliness, damaged areas, uneven flooring and locked storage since the inspection?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were used to calculate the overall rating. This explanation was written from the published report of 11 October 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 Salt Hill Care Centre
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- September 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2022Inadequatedown from GoodSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- August 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- July 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 8 March 2011.
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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