CQC report explained · a residential care home
What the CQC found at Spetisbury Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe, risks were assessed and reviewed, staffing was sufficient and medicines were administered on time by trained staff. Infection prevention arrangements were also found to be effective.
- Effective?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was used to calculate the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was used to calculate the overall rating.
- Responsive?
- Good
- Care plans were personalised and regularly updated. People were supported with communication, activities, relationships, complaints and advance care planning.
- Well-led?
- Good
- Inspectors found a positive culture, good communication and effective oversight. The concern about the home's culture was not substantiated.
What inspectors found, May 2023
Rated Good; inspectors found safe, personalised care and a positive culture, with no evidence of harm from the concern that prompted the inspection.
This was an unannounced focused inspection. One inspector and an Expert by Experience visited on 28 April 2023. They spoke with people, relatives, staff and health professionals, observed care and reviewed care, medicines, recruitment and management records.
The home was rated Good for Safe, Responsive and Well-led. People told inspectors they felt safe, received medicines on time and had care plans that reflected their needs and preferences. Staff were described as kind, supportive and well trained.
The inspection was prompted by concerns about the culture of the home. Inspectors found no evidence to support those concerns or that people were at risk of harm. The overall Good rating stayed the same as at the previous inspection in February 2020.
Effective and Caring were not reviewed during this focused inspection. Their previous ratings were carried forward when calculating the overall rating.
People felt safe
People and relatives told inspectors they felt safe. Risk assessments covered personal and environmental risks, and staff understood how to report abuse.
“People told us they felt safe living at the home. Their relatives agreed.” from the report
Medicines were managed well
Medicines were given on time and as prescribed. Records were complete, and staff had the required training and competency checks.
“People told us they received their medicines on time.” from the report
Personalised care
Care plans were detailed and updated when people's needs changed. People and relatives were involved in care planning and reviews.
“People's care plans were detailed, personalised and regularly updated as required.” from the report
Activities and relationships
People could choose from group and one-to-one activities, outings and time in the gardens. Relatives were welcomed and involved.
“People were supported and encouraged to take part in a range of activities.” from the report
Positive culture
People, relatives, staff and professionals described the home as pleasant and well managed. Inspectors found no evidence to support the culture concern that led to the inspection.
“The inspection did not find any evidence to substantiate the concern.” from the report
No registered manager in post
needs fixingThere was no registered manager at the time of the inspection. The manager had applied to register, but CQC was still considering the application.
“At the time of our inspection there was not a registered manager in post.” from the report
Limited secure medicines space
minorThe home said it was looking to increase storage space for medicines requiring stricter security because the existing area was limited.
“The manager told us they were looking to increase the safe storage space for these type of medicines as the current area was limited.” from the report
Recruitment was ongoing
minorThe home was recruiting additional staff, including for night shifts, when needed. Inspectors nevertheless found there were enough staff on duty during the inspection.
“The home was actively recruiting for additional staff including for night shifts for when they were required.” from the report
- 01Has the manager's application to register with CQC now been approved?
- 02What progress has been made in increasing the secure storage space for medicines requiring stricter security?
- 03How are night shifts staffed, and has the recruitment for additional night staff been completed?
- 04How will you continue to monitor and respond to any concerns about the culture of the home?
- 05What were the previous ratings for Effective and Caring, which were carried forward for this inspection?
This was an unannounced focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 31 May 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, February 2020
Spetisbury Manor was rated Good; inspectors found safe, kind and personalised care, while a registered manager was still being recruited.
This was an unannounced planned inspection. One inspector spoke with people living in the home, relatives, staff and a district nurse. They reviewed care records, medicines records, staff files, training information and management audits.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were protected from avoidable harm, received their medicines safely and had enough staff support.
People said staff were kind and respected their privacy, dignity and choices. Care plans reflected people's needs and interests. The home was being run by an acting manager while recruitment for a registered manager continued.
The overall rating stayed Good. The Well-led rating improved from Requires Improvement at the previous inspection, while the other four ratings remained Good.
Safe care
Inspectors found that risks were assessed and staff followed the guidance needed to reduce avoidable harm.
“People had their risks assessed and staff understood the actions needed to minimise avoidable harm.” from the report
Kind and respectful staff
People and relatives spoke positively about the care. Staff respected people's routines, privacy, dignity and independence.
“We observed warm, friendly relationships between people and the staff team.” from the report
Personalised support
Care plans reflected people's care needs, lifestyle choices and communication needs. Activities were tailored to people's interests.
“People had care plans which reflected their personal care needs and lifestyle choices, were understood by staff and reviewed regularly.” from the report
Improved management oversight
The systems for checking quality had improved since the previous inspection and included actions, deadlines and named responsibility.
“Improvements had been made to auditing systems and processes that meant they were effective at monitoring service delivery and regulatory requirements.” from the report
No registered manager in post
needs fixingThe home was being managed by an acting manager while a registered manager was being recruited. The report does not say whether this recruitment was completed afterwards.
“The home did not have a manager registered with the Care Quality Commission.” from the report
Some garden areas were not wheelchair friendly
minorNot all parts of the garden could be used easily by wheelchair users. Management said improvements to the paths were planned.
“Not all areas of the garden were wheelchair friendly.” from the report
- 01Has a registered manager now been appointed, and who is responsible for the home until that happens?
- 02What improvements have been made to the garden paths, and which areas can wheelchair users access?
- 03What is the current position on the Deprivation of Liberty Safeguards applications mentioned in the report?
- 04How are people's individual activities, communication needs and end of life wishes kept up to date?
- 05How can families give feedback, and how are suggestions about menus and activities acted on?
This was an unannounced planned inspection covering all five CQC questions; the overall rating was Good and the previous overall rating was also Good. This explanation was written from the published report of 27 February 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.
Every inspection of Spetisbury Manor
5 rated inspections over 8 years: the service has held its Good rating throughout.
- May 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2020Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Good
- March 2019Goodstayed GoodSafe: GoodWell-led: Requires improvement
- July 2017Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 6 December 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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