CQC report explained · a nursing home
What the CQC found at Strode Park House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2023
Rated Good overall; safe care still Requires Improvement, although the home is no longer in Special Measures.
This was an unannounced, comprehensive inspection following serious concerns at the previous inspection. Inspectors visited on 14 and 15 August 2023. They spoke with people, relatives and staff, observed care and checked care, medicine, recruitment and management records.
The home had improved since the previous inspection. Staffing levels were better, people were going out more often, activities had increased and inspectors found a more positive culture. People told inspectors that staff were kind, respectful and supported their independence.
The overall rating rose from Requires Improvement to Good. Effective, caring, responsive and well-led were rated Good. Safe was rated Requires Improvement because some medicine records and risk guidance were still not consistently complete, although the home was no longer in breach of regulations.
Improved staffing and activities
There were enough staff to provide care and support people to go out and enjoy activities. Agency use had reduced, although recruitment was continuing.
“There were now enough staff to support people with care but also for people to go out and enjoy activities.” from the report
Kind and respectful care
Inspectors observed compassionate interactions. People said staff respected their privacy, dignity, choices and independence.
“Staff spoke to people with compassion and kindness, they had developed relationships based on mutual respect and shared experiences.” from the report
Better care planning
Care plans had become more detailed and included people's preferences, communication needs and guidance for staff.
“Improvements had been made to the detail in people's care plan, they now included their likes and dislikes and how they like to be supported.” from the report
More effective oversight
Management systems were now identifying shortfalls and actions were being taken to reduce the chance of problems happening again.
“At this inspection, systems were established and had been effective in identifying shortfalls.” from the report
Access to health support
People had access to nursing care and a range of health professionals. Inspectors found examples of successful wound care and support with nutrition and fluids.
“People had access to healthcare professionals, the provider employed a multi-disciplinary team including physiotherapist, occupational therapist and speech and language therapist.” from the report
Medicine stock records
needs fixingSome records did not consistently show medicines that had been carried over. This could make it harder for staff to know when more medicine needed to be ordered. A new electronic system had been installed after the inspection.
“The recording of 'carried over' stock was not consistently recorded on MAR charts.” from the report
Catheter care guidance
needs fixingSome care plans did not explain when drainage bags and catheters should be changed or where this information should be recorded. The report says new care plans and guidance were introduced after the inspection.
“The care plans did not contain details about when staff should change drainage bags and information about when the catheter should be changed and where this information should be recorded.” from the report
Mixed views about meals
minorPeople had different views about the main meals. Some people said meals were disappointing, and management was considering changes to how meals would be provided.
“However, other people told us, the meals were a disappointment as they were not as good as the taster meals provided by the contractor.” from the report
- 01How are you checking that carried-over medicines are recorded correctly and reordered before stocks run out?
- 02What new guidance is now in place for catheter and drainage bag changes, and how do you check staff follow it?
- 03What changes have been made to the main meals since the inspection, and how are people asked for feedback?
- 04How many permanent and agency staff are currently working on each shift?
- 05How often can people go out and take part in activities, and what happens if staffing levels change?
This was an unannounced comprehensive inspection covering all five key questions and following up on previous Warning Notices; infection prevention and control was also checked. This explanation was written from the published report of 13 September 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, June 2023
Strode Park House was rated Requires Improvement overall, with Safe rated Inadequate; medicines and staffing were unsafe, and the home remains in special measures.
Inspectors visited without notice on 17, 18 and 19 April 2023. They spoke with people, relatives, staff and health professionals. They observed care and checked care plans, medicines, recruitment, training, incidents and other records.
The home had improved from Inadequate at the previous inspection, but important problems remained. Medicines were not always given safely, staffing levels sometimes fell below safe levels, and bed rail risks had not been fully managed. Infection control and record keeping also needed improvement.
People had mixed experiences. Some staff were kind and knew people well, but other care was task-focused. People were not always supported to communicate choices, leave the home, take part in activities or build independence. The new registered manager had been in post for three and a half weeks and had started improvement plans.
The home breached Regulations 9, 12, 17 and 18. CQC issued two warning notices about safe care and treatment and governance. Although the overall rating improved to Requires Improvement, the home remained in special measures because at least one key question had been rated Inadequate at two consecutive comprehensive inspections.
Safeguarding
People and relatives said they felt safe, and staff knew how to recognise and report possible abuse.
“People were being kept safe from potential abuse. People told us they felt safe, and relatives agreed with this.” from the report
Health support
People could access several health and social care professionals. Staff also recognised changes in people's health and sought advice.
“People had access to a range of health and social care professionals in line with their needs.” from the report
Consent and advocacy
People with capacity were asked for consent. People who lacked capacity had decisions made using the principles of the Mental Capacity Act, and advocacy was available.
“People who had capacity were asked for their consent before care was provided.” from the report
Open new leadership
The new manager and provider were open with inspectors and had begun plans to address the main risks.
“The registered manager and chief executive were open and transparent during the inspection.” from the report
Privacy
Staff were seen knocking before entering bedrooms and closing doors during intimate care.
“People's privacy was respected by staff. Staff were witnessed knocking on people's bedroom doors.” from the report
Medicines
seriousMedicines were not always managed safely. This included missed or incorrect doses, out-of-date medicines and records that could lead to dosing mistakes.
“Medicines were still not managed safely and placed people at risk of potential harm.” from the report
Staffing levels
seriousStaffing fell below the assessed safe level on several occasions. This meant some people received basic care but had little social contact or help to go out.
“Rotas demonstrated that on multiple occasions staff levels dropped below the assessed safe staffing level shared with us following the inspection.” from the report
Bed rail risks
seriousPeople using bed rails could become trapped or fall because rails were not always fitted or protected safely.
“People with bed rails were placed at risk of becoming trapped or falling despite risk assessments now being in place.” from the report
Communication and choice
needs fixingPeople with limited verbal communication did not have suitable alternative communication methods. This made it harder for them to express views and make choices.
“People who had limited verbal communication had not been provided with alternative methods of communication.” from the report
Infection control
seriousSome equipment and areas were dirty, and sluice room doors were not locked. This increased the risk of infection spreading.
“Systems were not in place to safely prevent the spread of infections.” from the report
Weak oversight
seriousManagement systems had not identified or acted on several important risks. The provider had also failed to make some required notifications.
“Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
- 01What immediate changes have been made to ensure all medicines are given as prescribed and checked against current instructions and blood tests?
- 02How often have staffing levels fallen below the home's assessed safe level since this inspection, and what is being done when that happens?
- 03What review has been completed of every person's bed rails, including the risks of entrapment and falling?
- 04What alternative communication methods are now available for people who cannot communicate verbally?
- 05What evidence can you show that the two warning notices and the breaches of Regulations 9, 12, 17 and 18 have been addressed?
This was an unannounced follow-up inspection of action required after the previous inspection, including infection prevention and control under Safe; all five key questions were rated, but the report does not describe this as a full comprehensive inspection. This explanation was written from the published report of 29 June 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.
Every inspection of Strode Park House
5 rated inspections over 8 years: the service has held its Good rating throughout.
- September 2023Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2023Requires improvementup from InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2023Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 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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