CQC report explained · a residential care home
What the CQC found at 1 & 2 Flax Cottages
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2020
Rated Good; inspectors found safe, kind and personalised care, with some records and activity planning still being strengthened.
This was a planned inspection on 24 January 2020. One inspector spent time with all six people living at the home, spoke with staff and the manager, checked care and medicines records, and contacted relatives and health and social care professionals.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, suitable training, good access to healthcare, and kind support that promoted privacy, dignity, choice and independence.
The home was working to improve its records of mental capacity assessments and best-interest decisions. Some activities had reduced during redecoration, and more accessible information and joint activities were being planned.
Safe staffing and medicines
Inspectors found enough staff to meet people's needs and a safe system for receiving, storing, administering and disposing of medicines.
“There were enough staff deployed to meet people's needs. Staffing was flexible and additional staff were placed on duty if additional activities were organised.” from the report
Kind, individual support
Staff knew people's preferences and could recognise non-verbal communication. They supported privacy, dignity, choice and independence.
“Staff were able to recognise and interpret people's non-verbal communication such as facial expressions and body language and responded to people's needs.” from the report
Good health support
People had access to healthcare professionals, annual learning disability health checks and hospital passports.
“People were supported to have access to a range of healthcare professionals to help ensure they remained healthy.” from the report
Positive leadership
The home used audits, checks, reviews, meetings and surveys to monitor quality and involve people and staff.
“A range of audits and checks were carried out to monitor the quality and safety of the service.” from the report
Mental capacity records
needs fixingThe manager was strengthening the records for mental capacity assessments and best-interest decisions so that all parts of the process were evidenced.
“The registered manager was strengthening their documentation relating to mental capacity assessments and best interests' decisions to ensure all areas of the process were evidenced.” from the report
Fewer recent activities
minorThere had been fewer activities while the home was being redecorated. More joint activities and events were planned with the nearby home run by the provider.
“There had not been as many activities carried out recently because of the redecoration programme.” from the report
Accessible information
minorEasy-read documents were available, but the manager said more work was planned to improve accessible information.
“The registered manager told us that further work was being planned to improve the availability of accessible information.” from the report
Size of the service
minorThe home was registered for up to nine people, which the report says is larger than current best-practice guidance. Inspectors said the building design and how staff worked reduced the possible negative impact.
“It was registered to provide accommodation, care and support for up to nine people. This is larger than current best practice guidance.” from the report
- 01What changes have been made to the records for mental capacity assessments and best-interest decisions?
- 02What activities are currently available, and have the planned joint activities started?
- 03How will you provide information in a form that the person can understand?
- 04How many people currently live here, and what would change if the home admitted more people?
- 05How are people's individual goals, preferences and communication needs reviewed?
This was a planned inspection covering all five CQC questions, and the report says the previous Good rating from 2017 remained unchanged. This explanation was written from the published report of 10 March 2020 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, September 2017
Rated Good; inspectors found kind, safe and person-centred care, with some repairs and activity planning still needing attention.
Inspectors visited without warning on 22 and 26 June 2017. They spent time with five people, spoke with staff, relatives and health professionals, and checked care plans, staff files and safety records. They also contacted relatives by telephone on 14 July 2017.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Medicines were stored, given and recorded safely. Staff were trained, there were suitable staffing levels, and people were supported with their health, nutrition, choices and daily activities.
People appeared relaxed with staff. Their rooms were personalised, care plans recorded their preferences, and staff promoted privacy, dignity and independence. Relatives and staff spoke positively about the management.
Some improvements were still needed. Repairs involving the landlord could take a long time, bathroom areas needed updating, and activity plans lacked detail. The overall rating had improved from Requires Improvement at the previous inspection because earlier medicines problems had been addressed.
Medicines were safer
The home had fixed the medicines problems found at the previous inspection. Inspectors found safe storage, clear instructions, complete records in the sample checked and proper procedures for covert medicines.
“At this inspection, we found that improvements had been made and medicines were being managed safely.” from the report
Kind and respectful staff
Staff knew people well and supported them in a warm, relaxed and respectful way. They promoted privacy, dignity and independence.
“We observed that staff were attentive and kind in their interactions with people.” from the report
Personalised support
Care plans included people's personalities, preferences and communication needs. Bedrooms were also made personal and homely.
“Person centred care plans were in place. This meant that people's personality, behaviour, likes, dislikes and previous experiences were taken into account when planning care.” from the report
Supportive management
Staff and relatives described the management as approachable and supportive. Regular checks and feedback systems were used to monitor the service.
“Regular audits were carried out to monitor the quality and safety of the service.” from the report
Delays to repairs
needs fixingThe report said repairs involving the landlord could take a long time. A broken tumble drier, rusty bathroom handrails and a rough temporary shelf were mentioned.
“There was a delay in a repair on the premises due to liaison required with the landlord.” from the report
Activity plans needed more detail
minorPeople had access to activities, but individual activity plans were not detailed enough. Reviews had started and the manager planned further improvement.
“Activity plans were lacking in detail. We spoke with the registered manager who told us having focused on a number of other areas form improvement since coming into post, they had plans to improve the range of activities and depth of activity planning.” from the report
Some audit records were missing
minorThe home carried out infection control checks but was not keeping its own records of those checks. The manager said this would be done in future.
“They were not, however, maintaining their own records of infection control audits.” from the report
One notification was missed
needs fixingThe manager had not sent CQC one required notification about a Deprivation of Liberty Safeguards application that had been granted. The report described this as an oversight.
“We found they had not submitted one notification related to a DoLS application that had been granted.” from the report
- 01What repairs or improvements involving the landlord are still outstanding, and how long are they expected to take?
- 02How have individual activity plans been improved since the inspection?
- 03Has staffing remained stable since the period of high staff turnover mentioned in the report?
- 04How are infection control checks now recorded and reviewed?
- 05What arrangements are in place to ensure all required notifications are sent to CQC on time?
This was an unannounced inspection looking at the overall quality and safety of the home, with relatives also contacted by telephone on 14 July 2017. This explanation was written from the published report of 8 September 2017 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 1 & 2 Flax Cottages
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- March 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- June 2013
Registered with the Care Quality Commission on 4 June 2013.
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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