CQC report explained · a residential care home
What the CQC found at 1 Charmandean Road
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Staffing, safeguarding, medicines and infection control had improved. However, staff did not always record or track incidents and risks in enough detail, and some risks did not have clear actions to reduce them.
- Effective?
- Requires improvement
- Care plans and staff training had improved, and people received appropriate food, healthcare and support with decisions. Communication and sensory assessments, longer-term goals and staff skills were still being developed.
- Caring?
- Good
- Inspectors saw kind and compassionate care. Staff respected people's privacy and dignity and supported people to take part in activities and express choices.
- Responsive?
- Good
- People had individual communication plans, more opportunities for activities and support to keep in contact with family. Relatives were encouraged to raise concerns and were involved in improvement discussions.
- Well-led?
- Requires improvement
- Senior managers had created an improvement plan and were more open and involved. Governance systems did not always monitor risks effectively, and there was not a registered manager in post.
What inspectors found, June 2022
1 Charmandean Road is rated Requires Improvement; inspectors found kinder care and better staffing, but safety records, communication and management systems still needed work.
This was an unannounced follow-up inspection on 19 April and 3 May 2022. Inspectors spoke with all eight people living in the home, five relatives, staff and visiting professionals. They observed care and checked care, medicine, training and management records.
The home had improved significantly since its previous inadequate rating. Staffing levels had increased, people had more activities and staff provided kind, respectful support. Inspectors rated Caring and Responsive as Good.
Some important work was still unfinished. Records did not always fully track incidents or risks. Communication plans and staff training were still developing. Management systems had not been tested long enough to show they worked consistently.
The overall rating was Requires Improvement. The home was no longer rated Inadequate or in Special Measures, and the provider was no longer in breach of the regulations found at the previous inspection.
Kind and respectful care
Inspectors saw staff showing warmth, empathy and compassion. People were supported with dignity, privacy and meaningful activities.
“Throughout the inspection staff repeatedly demonstrated genuine empathy and compassion.” from the report
Better staffing and activities
Staffing levels had improved, including support for people needing one-to-one care. This gave people more chances to go out and take part in activities.
“Staffing levels had improved and this had increased opportunities for people.” from the report
Improved safeguarding
Staff understood how to recognise and report abuse. Records showed concerns were reported appropriately and action was taken with other agencies.
“Staff were now clear about their role. They were identifying, reporting and taking appropriate actions.” from the report
More personalised communication
People had communication plans describing their preferred ways to communicate. Staff used different approaches to help people make choices and join in activities.
“People had individual communication plans that detailed effective and preferred methods of communication, including the approach to use for different situations.” from the report
Open improvement culture
Senior managers had acknowledged the earlier problems, sought feedback from relatives and put an improvement plan in place. Staff described feeling better supported.
“The provider took immediate action to improve the quality of the service following our last inspection.” from the report
Incident and risk records
needs fixingStaff did not always record incidents or sensory needs in enough detail to identify patterns. Some incident records did not show what further action would reduce the risk.
“Staff did not always record details. This increased the potential risk records were not sufficient to track and look for trends in incidents.” from the report
Communication skills still developing
needs fixingStaff understanding of communication was only basic in some areas. Further assessments, Makaton training and better plans were still needed.
“Staff understanding and assessment of communication was to a basic level and this was identified by the interim manager as an area which needed further training and development.” from the report
Governance and medicine auditing
needs fixingManagement checks did not always monitor risks or medicine processes effectively. The new systems needed more time to become established.
“The providers governance systems did not always effectively monitor risks to the health and safety of people.” from the report
No registered manager
minorThere was no registered manager in post during the inspection. The provider planned to recruit one while interim management continued.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01How are incidents, including self-injury and minor injuries, now recorded, reviewed and used to reduce future risks?
- 02What communication and sensory assessments have been completed, and when will the planned Makaton training be finished?
- 03How are medicine audits checking that PRN protocols contain enough information and that medicines are used safely?
- 04Who is responsible for the home while there is no registered manager, and what is the timetable for appointing one?
- 05How are people and relatives involved in decisions about the home and in checking progress against the improvement plan?
This was an unannounced comprehensive follow-up inspection covering all five key questions, including infection prevention and control, after the previous inadequate inspection. This explanation was written from the published report of 24 June 2022 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 2022
Rated Inadequate and placed in special measures; inspectors found serious risks involving safety, staffing, dignity and management.
This was an unannounced inspection over three days. Inspectors spoke with all eight people living in the home, relatives, staff and health professionals. They observed care and communication, and checked care, medicine, staffing and management records.
Inspectors found serious shortfalls. Incidents, including self-injury and possible abuse, were not always recorded, reported or investigated. There were not enough suitably skilled staff to meet people's assessed needs. One person was repeatedly left undressed in shared areas, and staff did not protect their privacy or dignity. Staff did not always understand people's communication methods, such as Makaton.
There were some positive findings. Medicines and infection control were managed safely, people had access to food and healthcare, and staff were often kind. However, the overall rating was Inadequate. Safe, Effective, Caring and Well-led were Inadequate, while Responsive Requires Improvement.
The provider took some action after the inspection, including increasing staffing and putting temporary measures in place around dignity. CQC required monthly updates and said it would re-inspect. The home was placed in special measures because of the Inadequate overall rating.
Safe medicines support
Inspectors found that staff supported people to take medicines safely. Guidance for medicines taken when needed was in place and medicines were regularly reviewed.
“People received their medicines safely in accordance with the prescriber's instructions.” from the report
Infection control
The home had effective arrangements for cleaning, infection testing, protective equipment and visits during the pandemic.
“The service used effective infection, prevention and control measures to keep people safe, and staff supported people to follow them.” from the report
Kind interactions
Although the overall caring rating was Inadequate, inspectors saw many staff using positive and respectful language and showing knowledge of people's likes and dislikes.
“Generally, people received kind and compassionate care from staff who used positive, respectful language which people understood and responded well to.” from the report
Personalised bedrooms
People were able to personalise their rooms and take part in decisions about their home environment.
“People personalised their rooms and were included in decisions relating to the interior decoration and design of their home.” from the report
People were at risk of avoidable harm
seriousIncidents, including self-injury and possible abuse, were not consistently recorded, reported or reviewed. Inspectors raised three safeguarding alerts during the inspection.
“The provider could not be assured people lived safely as risks had not been assessed, mitigated or monitored.” from the report
Insufficient staffing
seriousThere were not enough staff to provide assessed one-to-one support, personal care, meals and activities. Staff shortages also affected people's ability to go out and pursue their interests.
“The provider had not ensured that sufficient numbers of suitable, experienced staff were deployed to meet people's assessed needs.” from the report
Privacy and dignity were not protected
seriousOne person was repeatedly left undressed in shared areas, including near the front door. This affected the person's dignity and the privacy and comfort of others.
“The provider failed to ensure people were treated with dignity and respect. Staff failed to ensure people's privacy was maintained.” from the report
Communication support was inconsistent
needs fixingNot all staff understood or responded to people's individual communication methods, including Makaton and other signs or pictures. This increased the risk that distress or needs would be missed.
“People who had individual ways of communicating, using body language, sounds, Makaton (a form of sign language), pictures and symbols could not always interact comfortably with staff” from the report
Complaints were not trusted
needs fixingSome relatives and staff did not feel confident raising concerns because they were worried about confidentiality. The home could not show that all complaints had been properly investigated and used to improve care.
“The service was unable to evidence they had treated all concerns and complaints seriously, investigated them and learned lessons from the results.” from the report
Weak management oversight
seriousQuality checks had not identified serious problems with dignity, incident reporting, safeguarding, staffing and care records. Managers had not consistently learned from incidents or acted on feedback.
“Governance processes were not effective and did not always keep people safe, protect their human rights and provide good quality care and support.” from the report
- 01What staffing levels are now in place for people who need one-to-one or two-person support, and how are shortfalls covered?
- 02How are incidents of self-injury, possible abuse and unexplained injuries recorded, reported and reviewed now?
- 03What written plan and specialist support are in place to protect people's privacy and dignity when someone is undressed in shared areas?
- 04How are staff assessed and trained to understand each person's communication methods, including Makaton, pictures and body language?
- 05What changes have been made to management checks, complaints handling and learning from incidents since this inspection?
This was an unannounced inspection of the care home covering all five key questions, including infection prevention and control, the premises and the care provided. This explanation was written from the published report of 14 April 2022 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 report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of 1 Charmandean Road
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- June 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2022Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: InadequateResponsive: Requires improvementWell-led: Inadequate
- October 2017Goodstayed GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2020
Registered with the Care Quality Commission on 1 December 2020.
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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