CQC report explained · a nursing home
What the CQC found at Savernake View Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed, incident actions were recorded, staff were safely recruited and there were enough staff during the visit. Medicines and infection control were also found to be managed safely.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating.
- Well-led?
- Good
- Management had improved its oversight. Incidents and accidents were recorded and reviewed, notifications were submitted when needed, and people's current needs were included in handover information.
What inspectors found, December 2022
Rated Good after a focused inspection; inspectors found improved safety and management systems, with the provider no longer in breach of Regulation 17.
Inspectors visited without notice on 13 December 2022. They spoke with four people and six staff, reviewed care and medicines records, checked recruitment files and examined the home's quality and safety records.
They found people were protected from avoidable harm. Risks were assessed, incident records showed actions taken, staff were safely recruited and there were enough staff during the visit. Medicines and infection control were also managed safely.
The home had improved since the previous inspection, when it was rated Requires Improvement and breached Regulation 17 on good governance. Management checks, incident reviews, notifications and staff handovers had improved, so the provider was no longer in breach.
This was a focused inspection of Safe and Well-led only. The ratings for Effective, Caring and Responsive were carried forward from the previous inspection, so this visit did not reassess those areas.
Improved incident management
The home had improved how it recorded and reviewed incidents. Actions to reduce the chance of incidents happening again were recorded.
“All incident forms had been reviewed by management with action taken in response recorded.” from the report
Clear risk guidance
People's risks were assessed and support plans gave staff guidance. People who became distressed had detailed instructions to help staff respond consistently.
“People who experienced distress had detailed guidance in place which gave staff clear strategies on how to support people when they were distressed.” from the report
Enough and safely recruited staff
Inspectors saw enough staff to support people in a timely way. Required recruitment checks, including references and DBS checks, had been completed.
“During our inspection we observed there were enough staff available to support people in a timely way.” from the report
Good infection control
The home was clean and staff followed infection prevention guidance. PPE was available and used appropriately.
“The service was clean throughout and smelt fresh.” from the report
Visible management
The registered manager was visible and quality checks were taking place. People and staff had regular meetings where they could share views.
“The registered manager was visible at the service and kept systems under review.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you now record, review and follow up accidents and incidents involving residents?
- 02How do you check each person's current needs are passed on between shifts?
- 03How do you review staffing levels each day, and when do you use agency staff?
- 04What improvements have you seen since changing pharmacy suppliers, and how are medicines supplied without delays?
- 05What were the ratings for Effective, Caring and Responsive at the previous comprehensive inspection?
This was an unannounced focused inspection of Safe and Well-led, including infection control; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 31 December 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, October 2022
Rated Requires Improvement; inspectors found weaknesses in incident reporting and risk management, and issued a Warning Notice.
This was an unannounced focused inspection on 23 and 25 August 2022. Inspectors looked at whether the home was safe and well-led because of concerns about staffing and the high use of agency staff.
The home had enough staff on planned rotas, medicines were generally managed safely, and infection control was effective. People said they felt safe, and visitors were welcomed. The new manager was described as approachable and supportive.
However, incidents, safeguarding concerns and falls were not always recorded correctly or reviewed. Risk plans did not always tell staff how to support people safely, and handover records missed important information. The home remained rated Requires Improvement, with a continued breach of Regulation 17.
Medicines
Medicines were generally managed safely. Staff received training and their competence was checked.
“People's medicines were managed safely. The provider used an electronic medicines system which helped staff administer medicines safely.” from the report
Infection control
Inspectors found that infection prevention measures, including the use of protective equipment, were effective.
“At this inspection, we were assured that the provider was using PPE effectively and safely.” from the report
Staff recruitment
The home carried out the required recruitment checks before staff started work. Planned staffing numbers were recorded on rotas.
“The provider carried out the necessary recruitment checks prior to staff starting work.” from the report
New manager
People, relatives and staff gave positive feedback about the new manager's approach. They said the manager was approachable and supportive.
“Feedback about their approach was positive. Staff told us they found the registered manager to be supportive and approachable.” from the report
Family visits
People could receive visits from friends and relatives without restrictions. Inspectors saw visitors being welcomed.
“People had visits from friends and family when they wished, there was no restrictions on visiting.” from the report
Incidents were not reliably recorded
seriousSome safeguarding incidents and falls were recorded in the wrong place or not on incident forms. This meant managers could miss them and could not always show what had been done to prevent a repeat.
“Systems were not robust in assessing, monitoring and mitigating risk relating to the health, safety and welfare of people. This placed people at risk of harm.” from the report
Risk plans lacked detail
seriousSome people who experienced distress did not have clear guidance for staff. One risk plan did not accurately reflect previous physical altercations.
“People who experienced distress reactions did not have detailed guidance in place for staff to know how to support people safely.” from the report
Handover information was incomplete
seriousHandover sheets did not always tell staff about people who regularly experienced distress. This was more concerning because many agency staff worked at the home.
“As the service used high numbers of agency staff, this placed people at risk of harm.” from the report
Staffing pressure
needs fixingThe home generally had enough staff, but short-notice sickness made gaps difficult to fill. Some people said they sometimes had to wait for staff, and relatives raised concerns about weekend staffing.
“People told us at times they had to wait for staff, but they knew, and trusted staff would get to them.” from the report
One medicine was not always given on time
needs fixingOne person with Parkinson's disease did not consistently receive their medicine on time. The provider had identified this and was taking action.
“One person with Parkinson's disease had not consistently had their medicine on time.” from the report
- 01How are safeguarding incidents, accidents and falls now recorded, reviewed and reported?
- 02How will you make sure risk plans give agency staff clear instructions about people who may become distressed?
- 03How do you check that repositioning and other risk-monitoring records are completed correctly?
- 04How many agency staff are currently used, and how do you maintain continuity when permanent staff are absent?
- 05What action has been taken in response to the Warning Notice, and when will progress be reviewed?
This was a focused inspection of Safe and Well-led only; the other key-question ratings were not inspected and the previous ratings were used to calculate the overall rating. This explanation was written from the published report of 12 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 Savernake View Care Home
6 rated inspections over 5 years: the service has improved, from Requires improvement to Good.
- December 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- August 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- August 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- August 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2016
Registered with the Care Quality Commission on 25 August 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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