CQC report explained · a residential care home
What the CQC found at 12 Collett Close
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments, staffing and safeguarding arrangements had improved. However, infection testing was not always consistent, and staff had not always completed the required medicine checks.
- Effective?
- Requires improvement
- This key question was not inspected during this focused visit. The report used the previous inspection rating when calculating the overall rating.
- Caring?
- Requires improvement
- This key question was not inspected during this focused visit. The report describes kind and compassionate care, but does not give a current rating for Caring.
- Responsive?
- Requires improvement
- This key question was not inspected during this focused visit. The report describes personalised activities and support, but does not give a current rating for Responsive.
- Well-led?
- Requires improvement
- New audits and oversight systems had improved management. However, these systems were still being embedded and had not always identified gaps in staff records or a duplicate medicine record.
What inspectors found, May 2022
Rated Requires Improvement; inspectors found major progress since the previous inadequate rating, but safety and leadership checks still needed strengthening.
This was an unannounced focused inspection on 24 March 2022. One inspector spoke with people, relatives, staff and a professional. They reviewed care, medicine, recruitment and management records.
The home had improved its risk assessments, recruitment checks, staffing and quality monitoring. People were supported to make choices, stay active and take part in activities. Staff were described as kind and understood people's needs.
Some checks were still not reliable. Employment gaps and education details had not always been followed up, infection testing was inconsistent, and a duplicate medicine record had not been identified. The home improved from Inadequate and was no longer in Special Measures, but its overall rating was Requires Improvement.
Support for independence
Staff focused on what people could do and supported them to make choices, take part in activities and pursue their interests.
“Staff focused on people's strengths and promoted what they could do, so people had a fulfilling and meaningful everyday life.” from the report
Staffing levels
The home had enough staff, including support for one-to-one activities and visits.
“The service had enough staff, including for one-to-one support for people to take part in activities and visits how and when they wanted.” from the report
Kind and person-centred care
Inspectors found that staff understood people's individual needs, protected their dignity and supported their wellbeing.
“People received kind and compassionate care. Staff protected and respected people's privacy and dignity.” from the report
Recruitment records
needs fixingSome employment gaps had not been fully explored, and application forms did not always include education and qualification details. The manager took immediate action to collect the missing information.
“The provider had not requested a full employment history and gaps in employment had not been fully explored.” from the report
Infection testing
needs fixingStaff were not always completing lateral flow tests before every shift as required by the guidance at the time. The provider took immediate action.
“However, testing was not always consistent because the guidance had not been fully understood by the registered manager and staff.” from the report
- 01How do you now make sure every applicant's full employment history, education and qualifications are recorded and checked?
- 02How do you confirm that all staff complete the required lateral flow test before each shift?
- 03What checks now prevent duplicate medicine records, and how quickly would an error be found?
- 04How will you show that the new recruitment and medicine audits are fully embedded and effective?
- 05What are the current ratings and any outstanding issues for Effective, Caring and Responsive, which were not assessed in this inspection?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection when calculating the overall rating. This explanation was written from the published report of 6 May 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, September 2021
12 Collett Close was rated Inadequate and placed in special measures; inspectors found serious risks around fire safety, recruitment and management.
This was the first inspection of the newly registered home. One inspector visited the home, reviewed care, medicine and management records, and spoke with people, staff, a relative and health professionals.
Inspectors found serious safety problems. Fire risks had not been properly assessed or checked, staff had started work before DBS checks were received, medicines were not always managed safely, and some infection control arrangements were not adequate.
Care was not always based on up-to-date, detailed plans or people's views. People said they felt safe and supported, and staff were trained, but the home did not have effective systems to identify and reduce risks.
The overall rating was Inadequate. Safe and well-led were rated Inadequate, while effective, caring and responsive were rated Requires Improvement. The home was placed in special measures and is subject to registration conditions.
People felt safe
People told inspectors that they felt safe and supported. They found the registered manager approachable and felt able to share concerns.
“People told us that they felt safe and supported.” from the report
Trained staff
Staff had relevant training, induction and skills for their roles. They said they felt confident that the training was effective.
“People were supported by staff who were trained appropriately and had relevant skills and experience.” from the report
Choice and activities
People chose how to spend their time, and staff respected changes of mind. People were supported to take part in activities they enjoyed.
“We saw people were making choices about how they wanted to spend their time, and when people changed their minds this was respected by staff.” from the report
Health professional links
The home referred people to health and care professionals when extra support was needed.
“The service had clear systems and processes in place to refer people to external services, and additional support had been sought from health professionals as needed.” from the report
Fire safety
seriousFire risks had not been properly assessed or managed. Equipment checks were overdue, fire drills had not been practised, and a fire door had been propped open.
“Fire safety measures were inadequate placing people at risk of harm.” from the report
Unsafe recruitment
seriousStaff had been employed before DBS checks were received. Where a check showed a possible risk, the home had not completed adequate risk assessments.
“Staff were employed prior to their Disclosure and Barring Service checks (DBS) being received.” from the report
Medicines records
seriousMedicines were not counted regularly, so the home could not confirm that stocks were correct or that medicines had been given as prescribed.
“People's medicines were not counted regularly. This meant there was no way to know if the appropriate number of tablets were left in stock” from the report
Incomplete care plans
needs fixingSupport plans did not always contain current needs, preferences, routines or enough guidance for staff. People were not always involved in planning their care.
“People were not always supported to actively participate in their support plans.” from the report
Infection control gaps
needs fixingOne bathroom lacked soap, hand sanitiser or a way to dry hands. Cleaning schedules and the infection control policy were not fully in line with current COVID-19 guidance.
“We were not assured that the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
- 01What specific fire safety improvements have been completed, including updated risk assessments, equipment checks and fire drills?
- 02How do you make sure every staff member has the required DBS checks and risk assessment before working with residents?
- 03How are medicines now counted, monitored and recorded, including as-needed medicines and creams?
- 04How will you keep support plans up to date and involve each person in decisions about their care?
- 05What registration conditions are currently in place, and what evidence can you show of the improvements required by CQC?
This was the first inspection of the newly registered home and covered all five key questions, including infection prevention and control measures relating to COVID-19. This explanation was written from the published report of 14 September 2021 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 12 Collett Close
2 rated inspections over a year: the service has improved, from Inadequate to Requires improvement.
- May 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2021InadequateSafe: InadequateWell-led: Inadequate
- January 2020
Registered with the Care Quality Commission on 13 January 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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At least 100 live-in carers within about an hour of Dudley
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,230 a week. 88 can care for a couple. 10 years' experience on average.
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
“Knowing Mum was in Corina's care made an enormous difference to us and we knew she was in safe hands.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.