CQC report explained · a residential care home
What the CQC found at 1 Sheringham Avenue
Rated Outstanding: inspectors found the home performing exceptionally well.
What inspectors found, January 2020
Rated Outstanding; inspectors found safe, kind and highly personalised care, with exceptional responsiveness and leadership.
The inspection was unannounced and took place on 9 December 2019. One inspector spoke with three people, staff, relatives and professionals. They also checked care plans, medicine records, staff files, training records and management records.
The home supported five people with autism and mental health conditions. Inspectors found that people were safe, treated with respect and supported by trained staff. Medicines were managed safely overall, although one recording error was found and investigated on the inspection day.
The home was rated Outstanding overall. Safe, Effective and Caring were rated Good. Responsive and Well-led were rated Outstanding. The previous overall rating was Good, published on 30 June 2017.
Independence and choice
People were supported to learn life skills, use public transport and make decisions about how they spent their time. The focus was on helping people achieve their own goals.
“The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion.” from the report
Highly personalised support
Care plans gave detailed guidance about each person's autism, communication, preferences and sensory needs. Staff used people's strengths and interests to shape support.
“Care planning was highly person-centred. Care plans provided staff with comprehensive guidance around people's care needs and how staff should support people in a safe way whilst promoting learning and independence.” from the report
Meaningful activities
People had individual timetables based on their hobbies and aspirations. They were supported with volunteering, therapy, community activities, travel and holidays.
“People were supported to engage in a varied range of activities and pastimes, all designed to encourage social inclusion and independence.” from the report
Stable and skilled staff team
Many staff had worked at the home for several years. Staff received specialist training and worked together to avoid using agency staff.
“Many of the staff team had worked at the service many years which provided stability and reassurance to the people living at the service.” from the report
Strong leadership
The manager and staff shared clear values and used feedback, quality checks and improvement plans to develop the home.
“We found there were well established and effective governance systems to support the service to continually improve.” from the report
Medicine recording error
minorInspectors found a discrepancy in one person's medicines record. It was investigated on the day and identified as a recording error, with learning to be added to the medicines auditing process.
“However, we identified a medicines discrepancy for one person which was investigated by a senior support worker and registered manager on the day of the inspection.” from the report
- 01What changes were made to medicines audits after the recording error found at the inspection?
- 02How would you assess whether this home can meet my relative's particular autism and mental health needs?
- 03How are people supported to develop independence and take part in activities that interest them?
- 04How will my relative be involved in their care planning and decisions about daily life?
- 05How do you keep families informed if there is an incident, concern or change in care needs?
This was an unannounced planned inspection of the care home covering all five CQC questions, with accommodation and personal care both assessed. This explanation was written from the published report of 22 January 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, June 2017
1 Sheringham Avenue is rated Good; inspectors found caring, highly responsive support, but some risk assessments were incomplete.
Inspectors made an unannounced visit on 16 May 2017. They spoke with people, staff and managers, observed care, and checked care plans, risk assessments, medicines, training and other records.
The home supported up to four older people with autism and Asperger's syndrome. Inspectors found safe medicines management, enough staff, suitable training, respectful care and personalised support. The home was rated Outstanding for being responsive to people's needs.
Inspectors found that some risk assessments did not contain enough detail about diabetes and keeping other people safe. The home sent updated risk assessments after the inspection. Its audits had not found these issues, so inspectors recommended making the audit process more robust.
The overall rating was Good, and the home remained Good compared with the last inspection. This means inspectors found the service met the required standards overall, although some improvements were needed.
Support for independence
People were supported to take part in voluntary work, seek paid employment and build confidence and skills in the community.
“The home provided flexible, responsive support to assist people to live full and independent lives.” from the report
Personalised activities
Activities were matched to people's interests and included social groups, drama, bowling, pool, walking and overseas holidays.
“People participated in regular personalised activities, which included drama sessions, attending Autism Adult Social Groups and supported to travel abroad every year.” from the report
Kind and respectful care
People described staff as caring, and inspectors observed positive relationships. Staff respected privacy, dignity and independence.
“We observed that people had a positive relationship with staff and regularly engaged in conversation with people.” from the report
Safe medicines management
Medicines were stored securely and records were accurate. Staff had medicines training and said they were confident in managing medicines.
“Medicine records were completed accurately for all four people and were stored securely in a locked trolley.” from the report
Incomplete risk assessments
seriousSome risk assessments did not explain clearly enough how staff should manage diabetes or reduce risks to the person and members of the public. The home sent updated assessments after the inspection.
“This left the person at risk of serious health complications should their diabetes not be managed appropriately.” from the report
Audits missed these gaps
needs fixingThe home's checks and audits had not identified the weaknesses in the risk assessments. Inspectors recommended making the audit process more robust.
“However, the audits had not identified the issues we found with risk assessments.” from the report
- 01What do the updated risk assessments now say about managing diabetes and preventing serious health complications?
- 02How do risk assessments address safety risks to visitors and members of the public?
- 03What changes have been made to audits so gaps in risk assessments are identified promptly?
- 04How will support for voluntary work, paid employment and personalised activities be tailored to my relative?
- 05How are care plans reviewed when a person's health, risks or preferences change?
This was an unannounced inspection covering all five key questions, based on observations, discussions and checks of care, staff and management records. This explanation was written from the published report of 29 June 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 Sheringham Avenue
3 rated inspections over 4 years: the service has improved, from Good to Outstanding.
- January 2020Outstandingcurrent ratingup from GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Outstanding
- June 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Report published without a new overall rating.
- June 2014
Registered with the Care Quality Commission on 3 June 2014.
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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Most charge £980 to £1,260 a week. 79 can care for a couple. 11 years' experience on average.
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