CQC report explained · a nursing home
What the CQC found at Spencer House Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse, staff were safely recruited and trained, and infection control arrangements were in place. However, repositioning was not always completed within the required times, and some as-required medicines records were incomplete.
- Effective?
- Good
- This question was not inspected during this focused inspection. The previous rating was used in calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused inspection. The previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused inspection. The previous rating was used in calculating the overall rating.
- Well-led?
- Good
- The manager used audits and action plans to monitor the service and make improvements. People, relatives and staff could give feedback, although surveys had not been completed since 2019.
What inspectors found, July 2021
Spencer House Care Home was rated Good; inspectors found people felt safe, but some care and medicines records were not always followed or complete.
This was an unannounced focused inspection on 27 May 2021. The inspection followed concerns about staff knowledge and safe care. One inspector spoke with people, relatives and staff, and reviewed care, medicines, recruitment and management records.
The home was rated Good for Safe and Well-led. People told inspectors they felt safe and that staff were kind and caring. Staff were recruited safely, received training, and infection control arrangements were in place.
Inspectors found some shortfalls. Repositioning was not always completed within the required times, and records for some as-required medicines were incomplete. The manager put medicine protocols in place immediately. The other three questions were not inspected, so their previous ratings were used for the overall rating.
Safe recruitment and training
Staff were safely recruited and had training and induction to support people appropriately.
“People were supported by staff who knew them well and had been safely recruited.” from the report
People felt safe
People and relatives told inspectors they felt safe and were comfortable with the care provided.
“People and their relative's told us they felt safe with staff and were comfortable with the care given at Spencer House.” from the report
Infection control
Inspectors were assured that the home used PPE safely, followed social distancing arrangements and had measures to prevent and manage infections.
“We were assured that the provider was using PPE effectively and safely.” from the report
Management oversight
The manager used audits covering care plans, medicines, staff records and daily notes, with action plans to address issues.
“Audits were completed for a range of checks including care plans, medication administration charts, staff records and daily notes.” from the report
Repositioning was not always completed
needs fixingStaff did not always follow the required repositioning times intended to reduce the risk of pressure damage. Inspectors found no evidence of harm.
“However, staff had not always consistently followed these strategies.” from the report
As-required medicines records
needs fixingThe reason for giving some as-required medicines was not always recorded, and protocols were not always available. The manager put the protocols in place immediately after the inspection.
“However, when people were given 'as required' (PRN) medicines, staff had not always documented the reason for administering the medicine and the PRN protocol was not always in place.” from the report
Feedback surveys
minorThe home had systems for gathering views, but formal surveys had not been completed since 2019.
“However, surveys had not been completed since 2019.” from the report
- 01How do you check that repositioning is completed within the times set out in each person's care plan?
- 02How do you record the reason when an as-required medicine is given?
- 03Are up-to-date as-required medicine protocols now in place for every person who needs them?
- 04How do you collect relatives' views now that formal surveys had not been completed since 2019?
- 05What changes were made after the concerns about staff knowledge and safe care that led to this inspection?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were used for the overall rating. This explanation was written from the published report of 9 July 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, January 2018
Rated Good; inspectors found safe, kind and personalised care, with clinical leadership on one ward needing further development.
This was an unannounced comprehensive inspection on 6 November 2017. Inspectors observed care, spoke with 30 people, three relatives and 13 staff, and reviewed care, recruitment and quality records.
The inspection was brought forward after concerns about staffing levels on Blenheim Ward. The home had identified the problem and taken action. Inspectors found enough skilled staff to meet people's needs, although they recommended developing the clinical lead role as a priority.
All five areas were rated Good: safe, effective, caring, responsive and well-led. The report found that people were treated with respect, received personalised care, had their medicines safely managed, and could raise concerns.
Kind and respectful care
People described staff as kind, respectful and attentive. Inspectors saw staff protecting people's dignity during personal care and everyday support.
“People were treated with kindness and respect by staff.” from the report
Personalised care
Care plans recorded people's preferences, routines and health needs. Staff used this information to provide care in the way people preferred.
“Each person's care plan reflected their individual needs which staff followed to provide people's care.” from the report
Safe medicines and risk management
Inspectors found that risks were reviewed and medicines were given as prescribed. Staff knew when to seek medical advice about medicines.
“People received their prescribed medicines as planned as staff followed safe medicines management procedures.” from the report
Learning culture
The home used audits, meetings and incident reviews to identify improvements. Staff were encouraged to share ideas and learn from what happened.
“The service had an open culture which encouraged communication and learning.” from the report
Clinical leadership
needs fixingInspectors recommended developing the clinical lead role as a priority, to provide nursing staff with clinical support and development. The home had also recruited two more nurses for Blenheim Ward.
“We recommend that the role of clinical lead is developed as a matter of priority to allow for nurses clinical support and development.” from the report
- 01How has the clinical lead role been developed since the inspection?
- 02How many nursing staff are normally available on Blenheim Ward during the day and evening?
- 03How do you make sure bank or extra nursing cover is arranged when the ward is busy?
- 04How are care plans reviewed when a person's needs, preferences or health change?
- 05How will relatives' feedback and complaints be recorded, answered and used to improve care?
This was an unannounced comprehensive inspection covering all five questions, brought forward because of concerns about staffing levels on Blenheim Ward. This explanation was written from the published report of 3 January 2018 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 Spencer House Care Home
4 rated inspections over 6 years: the service has held its Good rating throughout.
- July 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2018Goodstayed GoodSafe: GoodWell-led: Good
- June 2016Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Registered with the Care Quality Commission on 2 October 2014.
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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