Country View Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety that encouraged openness and honesty. There were clear systems in place for reporting, investigating, and responding to accidents, incidents, complaints, and safeguarding concerns. Staff understood their responsibilities and were confident in raising concerns, reporting incidents, and escalating safeguarding issues when required.

Records showed that accidents and incidents were reviewed appropriately, with action taken to reduce the risk of similar events occurring in the future. Lessons learned from investigations were shared with staff to promote learning and improve the quality and safety of care provided.

Safeguarding concerns were managed appropriately, with referrals made to the relevant authorities when required. Statutory notifications were submitted to the CQC in line with regulatory requirements.

The provider worked with people, their families, and healthcare professionals to establish and maintain safe systems of care. There were effective arrangements in place to support safe admissions and transitions into the home, helping to ensure continuity of care and positive outcomes for people using the service.

Face-to-face pre-admission assessments were completed before people moved into the home. These assessments were detailed and involved people, their relatives, and relevant professionals where appropriate. This helped to ensure that the service could meet people's needs and that care was planned safely and effectively from the outset.

Hospital passports were in place to provide important information about individuals' needs and preferences, helping to ensure safe and effective transitions between the home and hospital services when required.

The provider had safeguarding policies and procedures in place to help protect people from abuse, neglect, discrimination, and avoidable harm. Staff understood their safeguarding responsibilities and there were clear systems for recording and reporting concerns. Safeguarding concerns were shared with the relevant authorities when needed.

Deprivation of Liberty Safeguards (DoLS) authorisations were in place for people who required them and these were reviewed regularly. Where conditions had been attached to authorisations, records showed the service had taken action to meet these requirements.

However, we found some restrictions used within the home, such as locked doors and lap belts, had not always been fully recorded in DoLS applications. This meant some restrictions had not been accurately reflected in the applications. We discussed this with the registered manager during the assessment. The provider assured us by the end of the assessment that they had already started reviewing and updating DoLS applications to ensure all restrictions were properly recorded.

The registered manager understood their responsibilities under the Duty of Candour and encouraged an open and honest approach when things went wrong. This helped to ensure concerns were shared appropriately and lessons could be learned.

The provider involved people in managing risks to their safety, however, systems were not always effective in helping people stay safe while maintaining their freedom. There were systems in place to assess, manage and monitor risks to people. Risk assessments covered areas such as falls, nutrition, and skin care. People told us they felt safe and that staff understood their needs.

However, care records and risk assessments did not always provide clear or up-to-date guidance to support consistent risk management.

Falls care plans and risk assessments were not always updated following incidents. For example, one person had experienced two falls since January 2026; however, there was no clear evidence of reviews, actions taken, or new control measures being implemented following the falls.

Two people's falls risk assessment scores were recorded as 0; however, sections of the assessments had not been completed accurately. For example, care records stated both people could become aggressive or distressed and required prescribed medicines when needed, but the falls risk assessment section relating to agitation and behavioural distress had been marked "No". This meant the assessments did not fully reflect the known risks and resulted in inaccurate overall falls risk scores. As a result, there was a risk that staff may not have a full understanding of the factors increasing the risk of falls or implement appropriate measures to reduce those risks.

While people told us they felt safe and risk assessments were in place, the concerns identified showed that risk information was not always accurate, reviewed, or detailed enough to ensure risks were consistently managed.

The provider gave assurances that risk assessments and care records would be reviewed to ensure risks were identified, monitored, and managed more effectively.

The provider identified and managed risks within the care environment and had systems in place to help keep people safe. Equipment, facilities, and the environment generally supported the delivery of safe care.

Checks of the premises and equipment were completed in line with guidance. These included water temperature checks, fire alarm testing, emergency lighting checks, fire extinguisher servicing, chair lift assessments, and gas and electrical safety checks. Equipment used to support people was easy for staff to access when needed.

People had Personal Emergency Evacuation Plans (PEEPs) in place to support them in the event of an emergency. Regular fire drills had been carried out to help ensure staff knew how to support people safely and effectively if an evacuation was required.

The home was well lit, with clear signage and wide corridors that were free from hazards. This helped people move around the home safely and as independently as possible.The provider told us that some parts of the building required updating and shared their maintenance improvement plan. This included plans to improve storage facilities and carry out roof works. A fire risk assessment had been completed by an external accredited company in March 2026. Although some areas for improvement had been identified, the manager told us they were putting a plan in place to complete the required actions within appropriate timescales.

However, wardrobes in bedrooms had not been secured to the wall and no individual environmental risk assessments had been completed to consider the risks this may present. While the provider had completed a general environmental risk assessment, people living at the home had high levels of dependency and complex needs. Individual assessments would have provided a more detailed review of risks and the measures needed to keep people safe. When these concerns were brought to the attention of the registered manager, they responded positively and gave assurances that risk assessments would be reviewed and updated to better reflect people's needs and risks in the future.

The provider made sure there were enough qualified, skilled, and experienced staff to meet people's needs safely. Staff received appropriate support, supervision, and training to help them carry out their roles effectively.

Staff were recruited safely and in line with safer recruitment procedures. Records showed that the necessary pre-employment checks had been completed before staff started work. Rotas demonstrated that shifts were consistently covered, helping to ensure people received the support they needed.

There was evidence that new staff completed an induction when they joined the service. A training and supervision matrix was in place to monitor staff compliance and provide management oversight. Staff supervision sessions took place regularly throughout the year, and staff appraisals were up to date.

There were enough staff on duty during our assessment, and staff were visible throughout the home. People appeared to receive support when they needed it.Feedback from people was positive about the skills and experience of staff. One person told us, "They do indeed; they do everything they need to"

The provider assessed and managed the risk of infection and had systems in place to reduce the risk of infections spreading. Staff understood their responsibilities for infection prevention and control.

The provider had an Infection Prevention and Control (IPC) policy in place which staff could access. Staff had received appropriate training and demonstrated an understanding of how to use and dispose of Personal Protective Equipment (PPE), such as gloves and aprons. During the assessment, we observed staff following good hand hygiene practices and using PPE correctly to help reduce the risk of infection.

The home was generally clean and free from unpleasant odours. There was sufficient PPE and cleaning equipment available throughout the home to support safe infection control practices.Relatives told us the home was kept clean and well maintained. One relative said, “No concerns, it’s kept clean.”

The registered manager knew where to access relevant guidance, including infection control and outbreak management information, and understood when concerns should be escalated to external professionals, such as Public Health and people's GPs.

The provider did not ensure that medicines and treatments were always managed safely or in a way that met people's needs, capacities, and preferences. We identified significant concerns relating to medicines management, record keeping, and covert administration, which reduced assurance that people were receiving their medicines safely and consistently.

The provider had a medicines policy in place. Staff had received medicines training, and their competency had been assessed to help support safe practice.

However, we identified a number of medication concerns during the assessment. These included missing opening dates on liquid medicines, incomplete pro re nata (PRN) guidance, and unclear recording on Medication Administration Records (MARs).

PRN (as required) protocols did not always provide clear guidance for staff about when PRN medicines should be given, or what monitoring was required. We also found there were no specific Mental Capacity Act (MCA) assessments or best interest records for some people receiving medicines covertly. For one person receiving covert medicines, there was no clear guidance from the GP or pharmacist explaining how medicines should be administered. The covert medication care plan was incomplete and did not clearly explain why covert medication was needed, what staff should do if the person refused food or drink, or how medicines should be administered safely and consistently. This reduced assurance that people's rights were being protected and that covert medicines were being administered in line with best practice.

MAR charts did not always clearly show medicines received, carried forward, or stock balances. Some handwritten entries were difficult to read, and reasons for medicine refusals or the effectiveness of PRN medicines were not consistently recorded. We also noted that when medicines were not administered or were refused, staff used a cross mark instead of recognised medication codes. In addition, medication stock balances did not always match the recorded balance counts for the people we checked.

These concerns demonstrated that medicines management systems were not always effective in ensuring medicines were administered, recorded, monitored, and reviewed safely. The registered manager acknowledged the concerns identified during the assessment and advised that medication practices and associated records would be reviewed.