CQC report explained · a nursing home
What the CQC found at Yardley Grange Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were supported safely, with risks identified and reviewed. Staffing, medicines, safeguarding, accidents and infection control were all found to be managed effectively.
- Effective?
- Good
- People's needs and preferences were assessed, staff had suitable training, and people received support with food, healthcare and decisions about their care.
- Caring?
- Good
- Inspectors saw kind and natural interactions. People were treated with dignity, involved in decisions and supported by staff who knew them well.
- Responsive?
- Good
- Care plans reflected people's preferences and were reviewed. People had activities, contact with relatives and support with communication, although some care reviews had lapsed.
- Well-led?
- Requires improvement
- The home had monitoring systems, but they did not identify several gaps. These included missing written recruitment risk assessment, lapsed care reviews, missing cleaning records and limited records showing feedback concerns had been followed up.
What inspectors found, May 2023
Rated Good overall, but inspectors found the home’s leadership and quality checks require improvement.
This was an unannounced inspection. Inspectors visited on 24 and 25 January 2023, spoke with people, relatives and staff, observed care, and checked care plans, medicines, recruitment and quality records.
People were found to be safe, supported by enough staff and given kind, respectful care. Their health, food, communication, activities and relationships were supported. Medicines and infection control were also found to be managed safely.
The overall rating was Good. Safe, Effective, Caring and Responsive were Good. Well-led was Requires Improvement because some quality checks had not found gaps in care reviews, recruitment records, cleaning records and follow-up of feedback.
Safe staffing
Inspectors found enough staff to support people, and staff attended to requests promptly. Recruitment checks were generally in place.
“There were sufficient staff available to support people and staff were recruited safely.” from the report
Kind and respectful care
People and relatives spoke positively about the care. Inspectors saw staff treating people kindly and respecting their privacy, dignity and independence.
“People were supported by a stable staff team who knew them well.” from the report
Personalised activities
The home offered group activities, entertainers and individual time for people who could not join communal activities. People were also supported to keep in touch with relatives.
“The home had a dedicated team of staff who supported people with group activities.” from the report
Healthcare support
People could access healthcare when needed. The home had links with a local GP practice and recorded people's healthcare needs.
“People were supported to access healthcare as and when needed.” from the report
Quality checks missed gaps
needs fixingThe home's monitoring systems did not identify that reviews with people and relatives had lapsed. The manager said these reviews would restart.
“The providers monitoring systems had not identified that reviews of care with people and relatives had lapsed.” from the report
Recruitment record
needs fixingIn one case, a written risk assessment was missing after recruitment checks found a criminal conviction. This was completed during the inspection.
“The providers recruitment policy had not been followed, in one instance, where a risk assessment should have been completed following recruitment checks for a staff member with a criminal conviction.” from the report
Cleaning records
minorStaff showed inspectors a daily cleaning task list, but there were no records to prove the tasks had been completed. A recording system was put in place after the inspection.
“However, monitoring systems had not identified there were no records available to show these tasks had been completed.” from the report
Following up feedback
needs fixingA survey contained concerns, but there was no written record showing how these had been followed up, even though managers described actions they had taken.
“However, where concerns had been raised there was no record available to demonstrate these had been followed up.” from the report
- 01How often are care reviews now completed with residents and relatives, and how are missed reviews tracked?
- 02How do you record and monitor completion of daily cleaning tasks?
- 03What written risk assessments are completed when recruitment checks identify a criminal conviction?
- 04How are concerns raised in surveys recorded, acted on and checked afterwards?
- 05What staffing is available to support residents who want to go on day trips?
This was an unannounced inspection covering all five CQC questions, including infection prevention and control; inspectors visited on 24 and 25 January, with inspection activity ending on 13 February 2023. This explanation was written from the published report of 4 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, April 2021
Inspected but not rated; inspectors found strong infection controls, but some environmental work and staff risk records still needed attention.
This was a targeted inspection on 10 March 2021. It looked only at infection prevention and control after a recent COVID-19 outbreak and earlier concerns about a specific care task.
Inspectors found that people were isolated or shielded when needed, staff were grouped to reduce infection spread, and testing, vaccination, cleaning and protective equipment were in place. Visits were suspended, except for people at the end of life.
The home was clean and policies were up to date. However, some parts of the building needed improvement, and risk assessments for staff at increased risk of COVID-19 needed to be recorded. The home was inspected but not rated, so this report does not give an overall quality rating.
Infection controls
The home had measures to reduce the spread of COVID-19, including isolating affected people, shielding vulnerable people and grouping staff.
“Action had been taken to reduce the risk of infection spreading in the home. This included the isolation of people affected by COVID-19, shielding of people who were vulnerable and the cohorting of staff to reduce the spread of infection.” from the report
Protective equipment
Staff were using protective equipment properly. Supplies were available, and arrangements were in place for safe removal and disposal.
“Staff were wearing PPE appropriately. There were sufficient supplies of PPE located around the service and arrangements were in place for staff to safely remove and dispose of PPE.” from the report
Testing and monitoring
People and staff were tested regularly, and people's health was monitored for COVID-19 and other infections. Most people and staff had been vaccinated.
“Regular testing in line with government guidelines for COVID-19 took place for people and the staff team.” from the report
Communication
The management team kept people, staff and relatives informed about the precautions being taken.
“The management team communicated regularly with people, staff and relatives to make sure everyone understood the precautions being taken, and how to keep people safe.” from the report
Environmental improvements
needs fixingAudits found some areas that were difficult to clean, including worn woodwork. Work was under way to seal the woodwork, replace some carpets with washable flooring and replace fabric notice boards.
“For example, improvements were taking place on worn and porous wood work areas that were difficult to clean, these were being re varnished and sealed so they could be cleaned effectively.” from the report
Staff risk records
needs fixingThe home needed to speak with all staff at increased risk of COVID-19 and record their individual risks and the actions needed to manage them.
“However, individual conversations with all staff identified as being at increased risk of Covid-19 needed to take place, so risks associated with the individual and actions identified could be documented.” from the report
- 01Have the worn and porous woodwork areas now been sealed and made easier to clean?
- 02Has the planned replacement of carpets with washable flooring been completed?
- 03Have all staff at increased risk of COVID-19 had their individual risks assessed and recorded?
- 04What higher level of protective equipment is required for the specific care task, and how is staff competence checked?
- 05How are visits currently arranged, including visits for people receiving end-of-life care?
This was a targeted inspection of infection prevention and control only; the report did not inspect or rate the other four areas of care. This explanation was written from the published report of 10 April 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.
Every inspection of Yardley Grange Nursing Home
4 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- May 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Inspected but not rated
- May 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2019
Registered with the Care Quality Commission on 10 July 2019.
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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