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CQC report explained · a residential care home

What the CQC found at 102 Faircross Avenue

Goodpublished 10 February 2024, 2 years ago

Rated Good: inspectors found the home performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
People were protected from abuse and avoidable harm. Medicines, risk assessments, staffing, infection control and safety checks were generally managed well, although the home was asked to review arrangements for people going out.
Effective?
Good
People's needs were assessed before they moved in, and staff had suitable training and supervision. Inspectors noticed that mental health awareness training was overdue, and the manager arranged a course.
Caring?
Good
People and relatives described staff as kind, caring and respectful. Staff knew people's histories, preferences and routines, and supported privacy, dignity, independence and choice.
Responsive?
Good
Care plans were personalised and covered communication, health, relationships, interests and daily living needs. People were supported with activities, family relationships and complaints.
Well-led?
Good
The manager and provider had systems to monitor care, medicines, safety and records. Inspectors found an open and supportive culture, with feedback from people, relatives, staff and healthcare professionals used to improve the home.
The latest report, explained

What inspectors found, February 2024

Rated Good; inspectors found kind, safe care, with a recommendation to improve flexibility for people going out.

One inspector made an unannounced visit on 8 January 2024. They spoke with all three people living in the home, one relative, the manager and a staff member. They reviewed care plans, medicines records, training, recruitment, incidents and infection control records.

The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that medicines were managed safely, risks were assessed, staff were kind, and care was tailored to people's needs and choices.

There was one recommendation about staffing arrangements. People needed staff support to go out, but there were only some times when two staff were available together. The home was also asked to improve how incident records captured lessons learned. The previous overall rating was Good in 2018, and this rating remained Good.

What inspectors praised
  • Kind and respectful staff

    People and relatives spoke positively about the staff. Inspectors observed polite and respectful interactions, with support given at people's own pace.

    “People and relatives told us staff were kind and caring. People's dignity, privacy and human rights were respected.” from the report
  • Safe medicines and risk management

    Medicines records were accurate and up to date. Staff understood people's risks, and the home carried out safety checks and maintained emergency plans.

    “We checked medicine administration records (MAR) and saw they were accurate and up to date.” from the report
  • Personalised support

    Care plans included people's health needs, communication, preferences, relationships, hobbies and daily living skills. Staff reviewed plans when needs or preferences changed.

    “Care plans contained details of people's daily living skills, communication needs, mental health, personal relationships, hobbies and interests, mobility, dietary and personal care needs.” from the report
  • Activities and relationships

    People were supported to maintain family and friendship links and to enjoy activities such as walks, music, shopping, eating out and exercise.

    “People were supported to pursue their own interests. Each person had a weekly activity schedule for which they were supported by staff.” from the report
What inspectors were concerned about
  • Limited flexibility to go out

    needs fixing

    People needed staff support when going out, but two staff were available together only at some times during the week. At other times, the home relied on the manager to provide cover.

    “This meant during other times, a staff member was reliant on the registered manager to provide cover if people wanted to go out.” from the report
  • Incident records did not always show lessons learned

    minor

    Managers reviewed incidents and took action, but the incident form did not always record what had been learned or how a repeat could be prevented. The manager said the form would be changed.

    “We saw from meeting minutes that lessons were learned from incidents although incident forms did not always capture this information due to their format.” from the report
  • Mental health training was overdue

    needs fixing

    Inspectors found that staff had not received mental health awareness training for a long period. The manager immediately arranged suitable training for all staff to attend later.

    “We noticed it had been a long period of time since staff had received training in mental health awareness.” from the report
Questions to ask them, based on this report
  1. 01How many staff are available when a person wants to go out at different times of the day and week?
  2. 02What changes have been made after the recommendation about giving people more flexibility and choice to go out?
  3. 03Has all staff mental health awareness training now taken place, and when will it be refreshed?
  4. 04Have the incident forms been changed to record lessons learned and how similar incidents can be prevented?
  5. 05How are each person's activity schedule, relationships and communication needs kept up to date?

This was an unannounced inspection covering all five rating areas, including the premises, care provided and infection prevention and control. This explanation was written from the published report of 10 February 2024 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 story over the years

Every inspection of 102 Faircross Avenue

3 rated inspections over 8 years: the service has held its Good rating throughout.

  1. February 2024Goodcurrent rating
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at 102 Faircross Avenue →

  2. May 2021Inspected but not rated
    Safe: Inspected but not rated
  3. January 2018Goodstayed Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
  4. February 2016Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
  5. September 2022

    Registered with the Care Quality Commission on 22 September 2022.

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.

Next steps

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