CQC report explained · a nursing home
What the CQC found at Seven Arches Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2020
Rated Good; inspectors found people were safe and the home was well-led after concerns were raised.
This was an unannounced focused inspection on 30 September and 2 October 2020. It followed concerns about staffing, risk management, infection control and management. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and management records.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe recruitment, appropriate risk plans and safe medicine systems. They were also assured about infection prevention, including the use of protective equipment and testing.
Inspectors found that the manager investigated accidents and concerns, used audits to identify problems and supported staff. The overall rating remained Good, as it was at the previous inspection, but this visit only examined Safe and Well-led.
Enough staff
Inspectors saw enough staff to meet people's needs, including one-to-one support at lunchtime. Recruitment checks were also in place.
“We observed there were enough staff throughout the inspection to meet people's needs.” from the report
Infection control
The home had arrangements for preventing and managing infection. Inspectors were assured that protective equipment, testing, cleaning and visiting procedures were being used.
“We were assured that the provider was using PPE effectively and safely.” from the report
Safe care planning
People's risks and medical needs had been assessed. Plans and equipment were in place to reduce risks such as pressure sores.
“Peoples risks had been assessed and plans had been put in place to manage and minimise risks.” from the report
Open management
The manager investigated concerns, involved health professionals when needed and used training and supervision to improve practice.
“The registered manager had investigated incidents thoroughly, sought support from healthcare professionals and carried out training and supervisions.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you currently monitoring the unexplained bruising mentioned in the report?
- 02What changes were made after audits identified concerns with skin care management?
- 03Have the planned menu changes been completed, and how are residents' food choices gathered now?
- 04How do you make sure agency staff understand residents' needs when they are used?
- 05What infection control and visiting arrangements are currently in place?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not examined during this visit. This explanation was written from the published report of 28 November 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.
What inspectors found, August 2019
Rated Good; inspectors found major improvements and kind, person-centred care, but some mealtime and activity support needed attention.
This was an unannounced planned inspection because the previous rating was Requires Improvement. Inspectors visited on 10 and 11 July 2019. They spoke with people, relatives, staff and health professionals, observed care, and checked care, medicines, recruitment and management records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found better systems for managing risks, safeguarding concerns, medicines and quality checks. People said they felt safe, and staff were described as kind, caring and knowledgeable.
There were still some areas to improve. Fluid charts were not always completed consistently. Inspectors also found variation in support at mealtimes, uncertainty about bathing choices, and too few one-to-one activities for people staying in their rooms. The report made recommendations about these points.
The previous inspection had found multiple breaches and rated the home Requires Improvement. At this inspection, inspectors found enough improvement for the home to be no longer in breach of the regulations.
Safer care systems
The home had improved how it identified and managed risks, including safeguarding concerns, falls, weight loss and choking. Staff knew people's risks and what action to take.
“Significant improvements had been made in how risks to people including potential safeguarding concerns were managed which protected people from the risk of harm and abuse.” from the report
Safe medicines practice
Inspectors found medicines were stored, given and recorded safely. Staff giving medicines had been trained and checked as competent.
“The storage, administration and disposal of medicines was undertaken safely, and in line with current professional guidelines.” from the report
Kind and respectful staff
People described staff as kind and caring. Inspectors saw positive interactions and found that privacy, dignity, independence and important relationships were supported.
“People's comments about the kind and caring nature of staff were universally positive.” from the report
Improved leadership
The new management had introduced stronger quality checks and encouraged an open, supportive culture. Staff, relatives and professionals reported positive changes.
“New quality assurance processes had been introduced to ensure more robust oversight of the safety and quality of the service at management and provider level.” from the report
Mealtime support
needs fixingSupport at mealtimes was not always consistent. Some people received rushed help, and staff did not always ask permission before assisting.
“There was some variation in the quality of support provided by staff and volunteers.” from the report
Bathing choices
needs fixingSome people were unsure whether they could choose when to have a bath or shower. The report recommended a more consistent approach to exploring and meeting these preferences.
“We recommend that the provider review their current systems and processes for exploring and meeting people's bathing preferences to ensure a consistent person-centred approach.” from the report
One-to-one activities
needs fixingActivities were mainly provided in communal areas. People who stayed in their rooms had fewer opportunities for individual activities, and inspectors recommended improvement.
“We found a lack of opportunities available for one to one activities for people who stayed in their rooms.” from the report
Fluid records
minorFluid charts were used, but the amounts people drank were not always recorded consistently. Inspectors said this appeared to be a recording problem because people were being supported to drink enough in practice.
“Fluid charts were used to monitor how much people drank but the amounts were not always consistently recorded.” from the report
- 01How do you make sure staff give calm, unhurried support at mealtimes and ask for permission before helping?
- 02How are each person's bathing preferences recorded, reviewed and followed?
- 03What one-to-one activities are available for people who spend much of their time in their rooms?
- 04How do managers check that fluid charts are completed accurately and consistently?
- 05What changes have been made since the previous Requires Improvement inspection, and how are you checking that they continue?
This was an unannounced planned inspection that looked at all five key questions, including the improvements made since the previous inspection. This explanation was written from the published report of 22 August 2019 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 Seven Arches Nursing Home
6 rated inspections over 6 years: the service has held its Good rating throughout.
- November 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- July 2018Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- December 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2015GoodSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 24 November 2010.
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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