CQC report explained · a residential care home
What the CQC found at 10 Spennithorne Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm, medicines were administered and recorded safely, and there were enough staff. A new fire risk assessment and an additional night support worker were still being arranged after fire service advice.
- Effective?
- Good
- Care plans, staff training, healthcare support and dietary arrangements helped meet people's needs. The home needed refurbishment, a structured competency assessment for some care tasks, and had delayed notifications to CQC about DoLS authorisations.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. They knew people's histories, communication and signs of distress, and relatives were involved when people could not take part fully in care reviews.
- Responsive?
- Good
- Care plans were detailed and person-centred. People had individual activity timetables, support to communicate and opportunities to visit local amenities and take part in activities they enjoyed.
- Well-led?
- Good
- The home had a positive, person-centred culture, supportive leadership and quality checks. Staff worked as a team and families were kept informed.
What inspectors found, June 2023
10 Spennithorne Road was rated Good; inspectors found kind, personalised care, with some follow-up needed on fire safety, the building and staff competency checks.
The inspection was unannounced and took place on 11 and 15 May 2023. One inspector observed care, spoke with one person, three relatives and five staff, and reviewed care, medicine, recruitment and management records. There was also an out-of-hours visit.
The home supports up to four people with learning disabilities and physical needs. Inspectors found enough staff, safe medicines practice, good personalised care and a warm, homely atmosphere. People were supported to make choices, stay active and access local places.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. This was the same overall rating as the previous inspection, published on 8 February 2018. Inspectors identified some matters needing action or improvement, but did not report any breached regulations.
Personalised care
Staff knew people well and supported their individual needs, choices and routines. Care plans gave clear guidance about how each person wanted to be supported.
“Detailed person-centred care and support plans were in place which provided information about each person’s preferences, choices and the support they needed.” from the report
Kind and respectful staff
Inspectors saw staff treating people with compassion and respecting their privacy and dignity. Staff adapted their approach to each person.
“Staff continued to demonstrate a strong commitment to providing compassionate care.” from the report
Choice and community life
People had individual activity timetables and were supported to use local shops, cafes, leisure and entertainment centres. Staff arranged rotas flexibly around people's wishes.
“People had individual timetables of activities, which included trips to local amenities, including shops, cafes, leisure and entertainment centres.” from the report
Safe medicines
Medicines were administered, stored and recorded safely, and records showed they were given as prescribed. Guidance explained how people preferred to take them.
“Peoples medicines were administered, stored and recorded safely.” from the report
Fire safety actions
needs fixingThe fire service had identified work that was partly complete and partly booked. A new fire risk assessment still needed to be completed, and extra night support was recommended.
“A new fire risk assessment needed to be implemented and completed by a competent assessor, assurances were provided this would soon take place.” from the report
Worn areas of the home
minorSome parts of the building looked worn and tired and needed refurbishment. An action plan with the landlord was in place.
“However, aspects of the home appeared worn, tired, and in need of refurbishment.” from the report
Staff competency checks
needs fixingInspectors found there was no structured competency-based assessment for some aspects of the care staff delivered. The provider commissioned bespoke training after the inspection.
“we found there wasn't a structured competency based assessment in place, to assess whether staff were competent to deliver this level of care.” from the report
Delayed DoLS notifications
needs fixingThere had been a significant delay in telling CQC about granted DoLS authorisations. The outstanding notifications were submitted during the inspection.
“During the inspection we established there has been a significant delay in notifying CQC of DoLS authorisations” from the report
- 01What work from the fire service action plan has now been completed, and has the new fire risk assessment been completed by a competent assessor?
- 02Has the additional night support worker been added to the staffing schedule?
- 03What refurbishment has been completed, or is still planned, for the worn and tired areas of the home?
- 04How are staff competency checks now carried out for the specialist care they provide?
- 05How do you make sure DoLS authorisations are notified to CQC without delay?
This was an unannounced inspection covering all five rating areas, the premises and the care provided, including an out-of-hours visit. This explanation was written from the published report of 1 June 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.
What inspectors found, February 2018
10 Spennithorne Road was rated Good; inspectors found safe, caring and highly individual support, with a minor recruitment-record gap.
This was an unannounced inspection on 8 January 2018. One inspector spoke with four relatives, managers and three care workers. They observed care, looked around the home and checked care, recruitment and management records.
The home supported four people with profound learning disabilities and physical needs. Inspectors found that people were safe, treated with kindness and dignity, and supported by staff who knew their needs, preferences and communication methods.
The home was especially responsive to individual needs. Inspectors saw detailed care plans, accessible information, activities chosen around people's interests, and examples of staff finding practical ways to increase safety and independence.
The overall rating was Good, with Good ratings for Safe, Effective, Caring, Responsive and Well-led. This was the same as at the previous inspection in August 2015.
Personalised care
Care plans were detailed and written in accessible formats. Staff understood people's routines, preferences and ways of communicating.
“Care records were individualised, person-centred and reflected the needs and wishes of the people who used the service.” from the report
Kind relationships
Staff were warm, patient and respectful. Inspectors saw people appearing relaxed, happy and comfortable with staff.
“Staff interacted with people in a very warm and friendly manner.” from the report
Individual solutions
Staff looked for practical ways to meet unusual or complex needs while reducing risks. One example was providing a large bean bag so a person could move to the floor more safely.
“The use of the bean bag has increased the person's safety and minimised the risk of the person injuring themselves.” from the report
Activities and family contact
People were supported to enjoy activities, outings, holidays and community events. Staff also helped relatives maintain contact when visits were difficult.
“The service continued to provide people with a flexible activities programme which responded to their abilities, preferences, choices, moods and well-being.” from the report
Incomplete employment histories
minorTwo staff records did not contain full employment histories. The manager said the application process would be amended, and the gaps were discussed and recorded retrospectively.
“However, we found two of the staff member's employment history had not been fully captured.” from the report
- 01What changes have been made to make sure every new staff member has a complete employment history recorded before starting?
- 02How will you find out and record the wishes of people who cannot communicate verbally?
- 03How are people's positive behavioural support plans and risk assessments reviewed when their needs or behaviour changes?
- 04How will you make sure staffing levels remain sufficient, including at night and during community activities?
- 05How are relatives involved in care plan reviews and decisions made under the Mental Capacity Act?
This was an unannounced inspection covering all five CQC questions; inspectors could not directly obtain the views of people living in the home because of their complex needs and communication styles. This explanation was written from the published report of 10 February 2018 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 10 Spennithorne Road
3 rated inspections over 8 years: the service has held its Good rating throughout.
- June 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- September 2012
Registered with the Care Quality Commission on 17 September 2012.
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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