CQC report explained · a residential care home
What the CQC found at West Hallam Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe and knew how to raise concerns. Inspectors found suitable systems for managing risks, medicines, staffing, safeguarding and infection control.
- Effective?
- Good
- This area was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found positive leadership, regular checks on quality and an open approach to feedback. People, relatives and staff spoke positively about the management.
What inspectors found, May 2023
Rated Good; inspectors found safe care and strong management, but this was a focused inspection of only two areas.
The inspection was unannounced and took place on 18 April 2023. One inspector and one Expert by Experience spoke with people, relatives, staff and visiting professionals. They also checked care, medicine, recruitment and management records.
The home was rated Good for Safe and Well-led. Inspectors found that people felt safe, risks were assessed, medicines were managed safely and there were enough trained staff. Infection control arrangements were also in place.
The home was described as welcoming and caring. People, relatives and staff gave positive feedback about the atmosphere and management. The overall Good rating stayed the same as at the previous inspection in 2018.
People felt safe
People and relatives said they felt safe and knew who to speak to if they had concerns. Staff understood how to recognise and report abuse.
“People felt safe at West Hallam Care Home.” from the report
Safe medicines support
Trained staff supported people with their medicines. The electronic system was checked daily and problems were acted on quickly.
“The management team had daily oversight of the system.” from the report
Enough trained staff
Inspectors found enough staff to support people, including people who needed two staff members for moving. Staff were trained to meet people's needs.
“There were sufficient staff available to support people.” from the report
Positive management
The home had systems for checking quality, listening to feedback and making improvements. People, relatives and staff described the management positively.
“A range of audits were carried out by the management team providing good oversight of the service.” from the report
Ongoing DBS checks
minorThe provider was considering changing its policy to include ongoing checks of staff DBS status. This was not recorded as a breach, but it is worth asking how the checks are managed now.
“The provider was considering a review of their policy to include ongoing checks of staff DBS status.” from the report
- 01Has the policy on ongoing DBS status checks been reviewed, and how are these checks carried out now?
- 02How does the home make sure there are enough trained staff when a person needs two staff members to support them?
- 03How are medicine records checked each day, and what happens when an issue is found?
- 04How can residents and relatives give feedback, and what changes have been made as a result?
- 05What were the ratings for Effective, Caring and Responsive at the 2018 inspection?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 19 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 2018
Rated Good; inspectors found kind, effective care, but some risk assessments and safety learning were incomplete.
This was the first inspection since the service was reregistered 12 months earlier. It took place on 14 and 15 December 2017, with the first day unannounced. One inspector observed care, spoke with people, relatives and staff, and checked records including three people's care files.
The overall rating was Good. All five areas were also rated Good: Safe, Effective, Caring, Responsive and Well-led. People generally said they felt safe, liked the staff, received their medicines on time, enjoyed the food and could raise concerns.
There were some shortfalls. Some risk assessments were incomplete, lessons from previous medicine incidents had not always been recorded, and some staff needed a better understanding of mental capacity rules. The home said it would take action on these points, and some changes were made after the inspection.
Kind and respectful care
Inspectors saw friendly, reassuring interactions. Staff respected people's privacy, dignity, independence and choices.
“This showed that people were treated with kindness, respect and compassion and that they were given emotional support they needed.” from the report
Medicines handled safely
Inspectors observed medicines being given safely, with staff staying until people had taken them. Records showed medicines were given as prescribed.
“Medicine records showed that people received their medicine as prescribed.” from the report
Individual care
Care plans included people's needs, histories, preferences and communication requirements. Staff were familiar with the people they supported.
“Care plans had included detail about people and their preferred lifestyles.” from the report
Incomplete risk information
seriousOne behaviour-related risk assessment did not give staff specific instructions. The report said this could put the person and others at risk if the behaviour was not managed properly.
“However, without comprehensive information in place there was a risk to the safety of the person and other people in the home due to the behaviour not being managed appropriately.” from the report
Learning from incidents
seriousEarlier medicine errors had occurred, but action showing lessons learned had not been recorded for one incident. The provider said action had been taken to address this.
“However, no action had been recorded to highlight any lessons learned for the other incident.” from the report
Staff knowledge of mental capacity rules
needs fixingSome staff could not explain their responsibilities under the Mental Capacity Act and deprivation of liberty safeguards. The manager said staff would be reminded of these issues.
“Some staff could not explain their responsibilities in relation to the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) were being followed.” from the report
Fire door left open
seriousInspectors found a fire door open when it had a sign saying it should be kept locked. The manager took action to lock it.
“However, we found a corridor cupboard fire door with a sign "Fire door keep locked" was open, which was a fire risk.” from the report
Training on health conditions
needs fixingStaff had not yet received training about some conditions, including stroke, epilepsy and diabetes. The manager said this would be reviewed and later provided confirmation of training to be arranged.
“However other training on people's conditions such as stroke, epilepsy and diabetes had not been provided.” from the report
- 01What specific changes have been made to ensure every person's risk assessment contains clear instructions for managing behaviours and other risks?
- 02How does the home now record and review lessons learned after medicine errors or other safety incidents?
- 03What training have staff completed on stroke, epilepsy, diabetes, mental capacity and deprivation of liberty safeguards?
- 04How does the home make sure fire doors and other fire safety measures are checked and kept secure?
- 05How do you respond when residents or relatives ask for more staff time and attention?
This was a comprehensive, unannounced inspection of all five key questions and the overall quality of the service. This explanation was written from the published report of 21 February 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 West Hallam Care Home
2 rated inspections over 5 years: the service has held its Good rating throughout.
- May 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2018GoodSafe: GoodWell-led: Good
- December 2016
Registered with the Care Quality Commission on 22 December 2016.
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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62 live-in carers within about an hour of Derbyshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,010 to £1,260 a week. 51 can care for a couple. 12 years' experience on average.
“Ernest is an amazing professional carer who delivers care from the heart.”
“We particularly appreciate the companionship Dawn gives in the evenings when she plays cards and Scrabble with my mother.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.