CQC report explained · a residential care home
What the CQC found at Spencefield Grange
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2022
Inspected but not rated; inspectors found good infection-control practice during a targeted COVID-19 review.
Inspectors visited the home on 26 January 2022. The visit was announced 12 hours beforehand and was targeted at infection prevention and control during the COVID-19 pandemic. They also asked about staffing pressures.
Inspectors were assured that the home used PPE safely, provided testing, managed outbreaks and kept its infection-control policy up to date. Visitors were tested, had their temperature checked and wore masks. Staff and visiting professionals had to show their vaccination status unless exempt.
The home was inspected but not rated. This means the report does not give a new overall quality rating or a rated result for Safe. It records what inspectors found during this focused infection-control review.
PPE and infection control
Inspectors found that PPE was available and used in line with current guidance. Staff had training on infection prevention and PPE.
“We were assured that the provider was using PPE effectively and safely.” from the report
Testing and outbreak management
The home had regular COVID-19 testing for people living there and staff. Isolation and grouping people together when needed were used to manage infection.
“A regular programme of testing for COVID-19 was in place for staff and people who lived the service.” from the report
Clean environment
Managers carried out regular checks and audits to make sure the home was clean and tidy.
“Management conducted regular checks and audits to ensure the service was kept clean and tidy.” from the report
Ventilation advice
minorThe inspector shared good-practice information about ventilation and signposted the home to further resources. Ask what actions were taken as a result.
“We have signposted the provider to resources to develop their approach.” from the report
- 01What changes did you make after the inspector shared advice about ventilation?
- 02How do you currently test people living here and staff for COVID-19?
- 03What are the current arrangements for visitors, including testing, masks and vaccination evidence?
- 04How would you manage a new infection outbreak, including isolation and grouping people together?
- 05Have staffing pressures changed since this inspection, and what measures are in place if they do?
This was a targeted inspection of infection prevention and control, with questions about staffing pressures; it was not a full inspection of all five areas and the service was inspected but not rated. This explanation was written from the published report of 16 February 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, August 2019
Rated Requires Improvement; inspectors found safe, kind and responsive care, but concerns about mealtimes, legal authorisations and management checks.
The inspection was unannounced and took place on 11 and 12 June 2019. Inspectors spoke with people living in the home, relatives, staff and a health professional. They also reviewed care records, recruitment files, training, medicines, safety checks and complaints.
The home was rated Good for Safe, Caring and Responsive. People were generally safe, treated kindly and involved in their care. Staff understood people's needs, medicines were stored and recorded safely, and relatives said they felt welcome and supported.
Effective and Well-led were rated Requires Improvement. Some people who needed help at mealtimes had to wait, staff were not always attentive, and supervision was not consistent. Care records were sometimes out of date, and the home had not initially obtained the required authorisation for some medicines given secretly in food.
The overall rating fell from Good at the previous inspection, published in October 2016, to Requires Improvement. The manager took action during or after the inspection on the medicines authorisations and corrected information in care records.
People were kept safe
Risk assessments, emergency plans, equipment checks and safeguarding procedures were in place. Recruitment checks were completed before staff started work.
“There were enough staff to meet people's basic care needs and keep them safe.” from the report
Kind and respectful care
People looked relaxed with staff and said staff were kind, respectful and helpful. Care plans recorded people's preferences and families were kept informed.
“People were respected, and their dignity protected.” from the report
Personalised support and activities
Staff knew people well and supported their interests, cultural needs, relationships and community activities. Families and friends were welcome to visit.
“People were encouraged to follow their interests and supported to take part in activities in the home and in the community.” from the report
Support at mealtimes
needs fixingPeople who needed help with eating sometimes waited for staff. When support was given, staff were not always as attentive as people needed.
“Those people who needed assistance were left waiting for staff to have the time to sit with them” from the report
Out-of-date care information
needs fixingAudits did not always identify inaccurate or conflicting information in care records. This meant staff might not have the most up-to-date information about someone's needs.
“The systems in place to audit and monitor the service were not always effective and information was not always kept up to date” from the report
Medicines given secretly
seriousThe home had not initially obtained the necessary legal authorisation or recorded best-interest decisions when some medicines were given hidden in food. Applications and records were completed after the inspection.
“People who were assessed as lacking capacity in relation to taking their medicines did not have DOLs authorisations in place” from the report
Limited time for people
needs fixingStaff had little time to spend with people outside basic care tasks. Some people were left waiting after meals and did not always have time to chat.
“However, staff had very little time to spend with people outside of delivering care.” from the report
- 01How do you make sure people who need help at mealtimes do not have to wait?
- 02How do you ensure staff have time to support people's social and emotional needs?
- 03How are care records checked and corrected when a person's needs or equipment change?
- 04Which medicines are given hidden in food, and how are the required authorisations and best-interest decisions recorded?
- 05How often do staff receive supervision and appraisals, and how do you make sure the schedule is followed?
This was a planned inspection of the home, including the premises and care, and all five CQC questions were rated; Safe, Caring and Responsive remained Good while Effective and Well-led fell to Requires Improvement. This explanation was written from the published report of 31 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 Spencefield Grange
3 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- August 2019Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 January 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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