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CQC report explained · a nursing home, run by Messrs A & M Desai - Desai Care Homes

Culverhayes Nursing Home

Lymore Avenue, Twerton, Bath, BA2 1AY

Goodpublished 23 December 2023, 2 years ago

Rated Good: inspectors found the service performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
People were supported safely, with safeguarding procedures, risk assessments, pressure area guidance, enough staff and safe medicines systems. Inspectors identified unlocked refurbishment rooms and chipped paintwork, but action was taken or planned during the inspection.
Effective?
Good
This area was not inspected during this visit. Its previous rating was carried forward.
Caring?
Good
This area was not inspected during this visit. Its previous rating was carried forward.
Responsive?
Good
This area was not inspected during this visit. Its previous rating was carried forward.
Well-led?
Good
Inspectors found a positive and open culture, clear roles, effective audits, appropriate complaint handling and good partnership working. Relatives said they were not always involved in care planning or reviews.
The latest report, explained

What inspectors found, December 2023

Culverhayes Nursing Home is Rated Good; inspectors found people were supported safely, but noted some smaller safety and involvement issues.

This was an unannounced, focused inspection on 1 November 2023. Inspectors checked whether people were safe and whether the home was well-led. They spoke with people, relatives, staff and the interim manager, observed care, and reviewed care plans, medicines records, recruitment files, complaints and audits.

The inspection followed concerns about personal care, pressure area care, and an allegation of physical abuse and neglect. Inspectors found no evidence that people were at risk of harm from these concerns. They found good safeguarding, enough staff, clear risk guidance and improvements in medicines checks since the previous inspection.

The home was rated Good overall, with Safe rated Good and Well-led rated Good. The other three areas were not inspected during this visit, so their previous ratings were used to calculate the overall rating.

What inspectors praised
  • Safeguarding and risk care

    Staff understood safeguarding and followed people's care plans and risk management guidance. Inspectors saw people being repositioned regularly and pressure-relieving equipment used appropriately.

    People were supported safely. Staff had a good understanding of safeguarding and acted in people's best interest where necessary.from the report
  • Staffing

    Inspectors found enough staff to support people safely. Staff recruitment checks were completed, although the approach to repeating DBS checks was not fully risk-assessed.

    There were enough staff to support people safely. One staff told us: "I have never experienced a staff shortage, the manager will arrange cover if it is needed.from the report
  • Medicines improvements

    The home had improved its medicines auditing since the previous inspection. Inspectors found medicines were stored safely and people received them as prescribed.

    At the last inspection we recommended the provider review their auditing processes around medication, particularly around identifying where medicines were not stored at safe temperatures and stock balances of medication. We found improvements had been made in these areas.from the report
  • Leadership and teamwork

    Staff described a positive team culture, regular supervision and useful training. Inspectors found clear roles, effective audits and appropriate handling of the one complaint received since the previous inspection.

    There was a positive and open culture within the service. Staff described the service as a "whole team process" which worked well.from the report
  • Activities and outside support

    People could choose from individual trips, group activities and activities at the home. The home worked with health professionals and made referrals when needed.

    There were different types of activities available such as 1:1 trips out, group activities and 1:1 activities at the service.from the report
What inspectors were concerned about
  • Unsecured refurbishment rooms

    serious

    Two rooms contained paint cleaner and power tools and were left unlocked and unattended at points during the inspection. The manager acted after this was raised, but this could have put people living with dementia at risk.

    These rooms were left unattended and unlocked at points throughout our inspection, which could have presented a risk to people living with dementia.from the report
  • Chipped paintwork

    needs fixing

    Some paintwork was chipped and needed repair. Inspectors said this could prevent effective cleaning and create an infection control risk. The home said repairs were part of ongoing maintenance work.

    This presents an infection control risk as it prevents these areas from being cleaned effectively.from the report
  • DBS checks

    minor

    Recruitment checks had been completed, but DBS checks were not repeated at regular intervals in line with best practice. The home had not shown that it had considered the risk of this approach.

    However, it was not evident the risk of this had been considered.from the report
  • Family involvement

    minor

    Some relatives said they were not always involved in care planning or care plan reviews. The home explained its review process and later held a meeting to explain it to relatives.

    Relatives told is they were not always involved in the care planning process or care plan reviews of their relative.from the report
Questions to ask them, based on this report
  1. 01How will you make sure refurbishment rooms are locked and safe whenever work is taking place?
  2. 02When will the chipped paintwork be repaired, and how do you manage the infection control risk while this is outstanding?
  3. 03How do you decide when staff DBS checks should be repeated, and how is that risk recorded?
  4. 04How will you make sure relatives are invited to care planning meetings and care plan reviews?
  5. 05Which areas of care were not assessed during this inspection, and when were they last reviewed?

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 23 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.

The story over the years

Every inspection of Culverhayes Nursing Home

4 rated inspections over 8 years: the service has held its Good rating throughout.

  1. December 2023Goodcurrent ratingstayed Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at Culverhayes Nursing Home

  2. June 2023Goodstayed Good
    Safe: GoodWell-led: Good

    We are reading this report · the original is on cqc.org.uk

  3. July 2018Goodstayed Good
    Safe: GoodWell-led: Good

    Read this report on cqc.org.uk

  4. January 2016Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read this report on cqc.org.uk

  5. February 2014

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  6. October 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  7. July 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  8. May 2011

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  9. January 2011

    Registered with the Care Quality Commission on 13 January 2011.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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