CQC report explained · a nursing home
What the CQC found at Warren Court
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2023
Rated Requires Improvement; inspectors found enough staff and some good support, but identified risks to dignity, personalised care and service oversight.
The inspection was unannounced and took place on 26 September and 12 October 2023. Inspectors spoke with 12 people, four relatives, six staff members and a visiting health professional. They also reviewed care plans, medicines records, staff files and management records.
The home was rated Requires Improvement overall and in all five areas. Inspectors found that toilet privacy was not always protected, care plans did not always reflect people's preferences, and risks after falls and social isolation were not always managed well. They also found mixed views about how caring staff were.
There were positive findings too. Staffing levels and staff training were considered suitable. Medicines were managed safely, people had access to healthcare, and people said they could raise concerns. However, the home's quality checks had not identified important shortfalls.
The previous rating was Good, published in September 2017. CQC found a breach involving dignity and respect and another involving good governance. The provider must send an action plan, and CQC will monitor progress with the provider and local authority.
Staffing and training
Inspectors found enough staff on shift and found that staff had suitable training, induction and experience.
“The provider always had sufficient numbers of staff on shift to support people's care needs effectively.” from the report
Healthcare support
The home worked with GPs, the pharmacy and other health professionals. People were supported to attend appointments and receive healthcare.
“The provider worked with other agencies to provide consistent, effective, and timely care.” from the report
Food and drink
People said they were happy with the food. The kitchen was clean and had a five-star food hygiene rating.
“People were supported to eat and drink enough to maintain a balanced diet.” from the report
Medicines
Inspectors found systems for managing medicines, including regular audits and cooperation with the pharmacy and GP.
“The provider had measures in place to ensure that medicines were managed and administered safely.” from the report
Open management
People, relatives and staff said they could speak to managers and raise concerns. Staff described the managers as approachable and supportive.
“Staff said they felt respected and supported by the registered manager.” from the report
Privacy and dignity
seriousA person used a toilet in view of the reception area, and toilet doors did not have locks at the time of inspection. Locks were fitted after the inspection, but this was a breach.
“The provider had not ensured people's privacy was always maintained.” from the report
Responding after falls
seriousMedical advice was not always sought promptly after a fall. Inspectors also found that records did not always explain what action had been taken or what had been learned.
“Medical advice was not always promptly sought after people had a fall.” from the report
Personalised care plans
needs fixingCare plans did not always include people's preferred routines, food choices, goals, aspirations or equality needs. The manager said this information would be gathered and added.
“People's care plans did not always have information about people's life choices, like choice of food or preferred daily routine, or goals and aspirations.” from the report
Social isolation
needs fixingSome people who received care in bed did not leave their rooms. Inspectors found their social contact was mainly with care workers, health professionals and occasional family visitors.
“The only social contact these people had was with health professionals and care workers delivering care or when family members occasionally visited.” from the report
Mixed views about care
needs fixingPeople gave both positive and negative feedback about staff attitudes. One concern involved a care worker holding people's wrists rather tightly, which was raised with the manager.
“We received mixed feedback about the caring attitude of care workers.” from the report
Weak quality checks
seriousThe home's monitoring systems had not found or dealt with several of the problems identified by inspectors. This was a breach of good governance.
“The lack of effective quality assurance mechanisms put people at risk of not receiving good quality care.” from the report
- 01What changes have been made to protect toilet privacy, and how are these changes now checked?
- 02What is the home's procedure for getting medical advice after a fall, and how are lessons from falls recorded?
- 03How will you record and provide each person's preferred daily routine, food choices, goals, equality needs and personal preferences?
- 04What activities or regular contact are available for people who receive care in bed and may be socially isolated?
- 05What actions are in the improvement plan for the two breaches, and how will families be shown that they have been completed?
This was an unannounced inspection covering all five key questions, including the premises, care, records, staff arrangements and management systems. This explanation was written from the published report of 21 December 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 2022
Warren Court was inspected but not rated; inspectors found strong COVID-19 infection control arrangements.
This was an announced, targeted inspection on 27 January 2022. Inspectors looked at infection prevention and control, visiting arrangements and the effect of COVID-19 staffing pressures.
Inspectors were assured that the home checked visitors' vaccination status, lateral flow test results and temperatures. They also found suitable social distancing, effective use of protective equipment, safe admission arrangements and testing processes.
The service was inspected but not rated. This means the inspection did not give an overall quality rating or a rated judgement for safety.
Visitor checks
The home checked visitors' vaccination status, lateral flow test results and temperatures before entry. Spare tests, face masks and hand gel were available.
“The provider had a robust system in place to ensure that visitors and external staff entering the premises had their vaccination status and lateral flow tests (LFT) checked.” from the report
Social distancing
Communal areas were arranged to help people keep apart, and inspectors saw staff following protective equipment and distancing guidance.
“Our observations during the inspection confirmed staff were adhering to personal protective equipment (PPE) and social distancing guidance.” from the report
Safer admissions
New admissions were kept in their rooms for 14 days and needed three negative lateral flow tests on consecutive days, according to the provider.
“The provider told us that new admissions were nursed in their room until a 14 day period had passed, and three negative LFTs had been obtained over consecutive days.” from the report
Support for vulnerable staff
Staff who were more vulnerable to COVID-19 had been assessed, with plans intended to reduce risks to their health and wellbeing.
“The provider had ensured staff who were more vulnerable to COVID-19 had been assessed and plans were in place to minimise the risk to their health and wellbeing.” from the report
Inspectors raised no specific concerns in this report.
- 01How are visitors' vaccination status, lateral flow tests and temperatures checked now?
- 02Do new admissions still stay in their rooms for 14 days and have three negative lateral flow tests on consecutive days?
- 03What measures are currently used when COVID-19 creates staffing pressures?
- 04How are visits being facilitated now, and what infection control rules apply?
- 05What approach did the provider develop after being signposted to further infection prevention and control resources?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated. This explanation was written from the published report of 10 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.
Every inspection of Warren Court
3 rated inspections over 9 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- September 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2014
Registered with the Care Quality Commission on 30 April 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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