CQC report explained · a residential care home
What the CQC found at 135 Tennyson Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough suitably trained staff, safe medicines systems and risk assessments that were reviewed. The home was clean, and staff understood safeguarding procedures.
- Effective?
- Good
- Staff used health guidance, worked with health professionals and supported people with food, drink and healthcare. They understood consent and mental capacity requirements.
- Caring?
- Good
- People said staff were kind and caring. Staff respected privacy, involved people in decisions and encouraged independence.
- Responsive?
- Good
- Care plans were detailed and personalised, and staff supported communication, activities and relationships. However, end-of-life wishes had not been discussed or recorded.
- Well-led?
- Good
- The home had an open, person-centred culture. Audits, meetings and feedback were used to identify and address improvements.
What inspectors found, February 2020
Rated Good; inspectors found kind, safe care and improvements since the last inspection, but end-of-life wishes had not been recorded.
One inspector visited on 9 January 2020. They spoke with one person and two staff members, and checked care records, medicines records, complaints and quality checks.
The home was rated Good in all five areas. Inspectors found enough trained staff, safe medicines practice, kind care, personalised support and good management. People were happy with the care and staff.
The main shortfall was that staff had not discussed people's end-of-life wishes with them or their relatives. The inspector recommended that this information be added to care records.
The previous inspection rated the home Requires Improvement and found a breach linked to first-floor windows. Improvements had been made, and the home was no longer in breach at this inspection.
Kind and respectful care
People said staff were kind and caring. Staff respected privacy and involved people in decisions about their support.
“People liked the staff that cared for them. Staff were kind and caring, they involved people in their care and made sure people's privacy was respected.” from the report
Safe staffing and medicines
Inspectors found enough staff with the right skills. Medicines were given as prescribed and records were completed accurately.
“There were enough staff. The provider obtained key recruitment checks before new staff started work.” from the report
Personalised support
Care plans gave staff detailed guidance about people's needs, preferences and mental or psychological health. People were encouraged to build independence.
“People had care and support plans in place, which were personalised and written in detail.” from the report
Improvement since the last inspection
The previous inspection found a breach and rated the home Requires Improvement. Inspectors found that the required improvements had been made.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
End-of-life wishes not recorded
needs fixingStaff had not discussed end-of-life preferences with people or their relatives. The inspector recommended updating care records with this information.
“Staff had not spoken with people or their relatives about end of life wishes, although no-one was receiving end of life care at the time of our visit.” from the report
- 01How will you discuss and record my relative's end-of-life wishes in a way that respects their feelings and capacity?
- 02How do you make sure care plans stay up to date when a person's needs or mental health changes?
- 03How will you support my relative to make choices and remain as independent as possible?
- 04How do you make sure medicines, including creams and medicines given only when needed, are recorded correctly?
- 05What improvements were made after the previous inspection's concerns about first-floor windows?
This was a planned inspection covering all five CQC questions, including the care provided and the premises; the previous rating was Requires Improvement. This explanation was written from the published report of 14 February 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, January 2019
Rated Requires Improvement; inspectors found kind, personalised care, but unsafe first-floor windows led to a legal breach.
The home was inspected without notice on 12 November 2018. One inspector spoke with one resident, two staff members and the registered manager. They also checked care records, staff files, training records, medicines and complaints information.
The main safety problem was that first-floor windows could be opened wide enough for someone to climb out. The home supported people with learning disabilities and had not identified this as a risk. Window restrictors were not in place, so the premises were not fully safe.
The inspectors found enough staff, safe medicines practices, appropriate recruitment checks and a clean home. Care was effective, kind and personalised. The home was rated Good for Effective, Caring, Responsive and Well-led, but Requires Improvement for Safe, making the overall rating Requires Improvement.
The previous inspection in May 2016 rated the home Good. After this inspection, the manager said work had started to install suitable window restrictors.
Safe medicines
Inspectors found that medicines were stored securely, given correctly and recorded accurately. Staff had been trained and felt confident administering them.
“Medicines were managed safely.” from the report
Kind and respectful care
People described positive relationships with staff. Inspectors observed respectful communication and support that allowed people time to express their wishes.
“People felt well cared for.” from the report
Personalised support
Care plans recorded individual preferences and communication needs. Staff supported people to work towards personal health goals and manage difficult situations.
“Care was personalised to each individual.” from the report
Good involvement
People and relatives were involved in care reviews and could give feedback about activities, trips and food choices. The home acted on feedback.
“People using the service were encouraged to feedback at resident's meetings” from the report
Unsafe first-floor windows
seriousThe windows could be opened wide enough for a person to climb out. This was not identified as a risk for the people living in the home and led to a breach of regulations.
“All of the windows on the first floor of the building, including people's bedrooms, did not have effective window restrictors on them.” from the report
Safety checks missed the problem
needs fixingEnvironmental audits did not identify that the window latches could be disabled by hand. The manager said work had started after the inspection, but the report does not confirm that it was complete.
“Audits did not pick up on the lack of appropriate window restrictors” from the report
- 01Have restrictors now been fitted to every first-floor window, including bedroom windows?
- 02How are the new restrictors checked to make sure they cannot be disabled or opened too far?
- 03What other environmental risks were identified or addressed after the CQC inspection?
- 04How are environmental audits now carried out so that safety problems are not missed?
- 05What improvements have been made since the previous Good rating in May 2016?
This was an unannounced inspection covering all five CQC questions; one inspector spoke with one resident, two staff members and the registered manager and reviewed care and management records. This explanation was written from the published report of 11 January 2019 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 135 Tennyson Road
3 rated inspections over 4 years: the service has held its Good rating throughout.
- February 2020Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 26 January 2011.
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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