CQC report explained · a residential care home
What the CQC found at 13a Repton Drive
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risks were assessed and reviewed, including risks linked to equipment, eating and drinking. Medicines were stored, administered and recorded safely by trained staff.
- Effective?
- Good
- Staff had relevant training and support. The home was following the Mental Capacity Act and Deprivation of Liberty Safeguards, and people's health and nutritional needs were monitored.
- Caring?
- Good
- Inspectors saw kind and patient interactions. People's privacy, dignity, culture, religion, choices and preferred ways of communicating were respected.
- Responsive?
- Good
- Care plans were detailed and personalised, and were reviewed every six months or when needed. People were supported to take part in activities they chose and to raise complaints.
- Well-led?
- Good
- The home had a registered manager and regular quality audits. Inspectors found that monitoring systems had been improved and were being used to identify and complete actions.
What inspectors found, October 2017
13a Repton Drive was rated Good; inspectors found safe, kind and personalised care, with improvements made since the previous inspection.
This was an unannounced comprehensive inspection on 12 September 2017. One inspector met the six people living at the home, observed their care, and spoke with relatives, staff, the manager and visiting professionals. Records about care, medicines, staffing and quality checks were also reviewed.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that medicines were managed safely, staffing was suitable, risks were assessed, and staff had the training and support needed for their roles.
People had detailed care plans that reflected their needs, communication methods and preferences. Staff were described as kind and respectful. People were supported with health, food, activities, relationships and complaints.
At the September 2016 inspection, the home was rated Requires Improvement and had three breaches. This inspection found that the required improvements had been made, including better capacity assessments, personalised care plans and quality monitoring.
Safe medicines support
Medicines were securely stored and records were accurate. Staff who administered medicines had training and competency checks.
“The staff responsible for administering medicines had received training and had their competency tested.” from the report
Personalised care
Care plans gave staff clear information about people's needs, communication and preferences. They included guidance from health professionals where needed.
“The care plans were personalised and covered all areas, which people required support with.” from the report
Kind and respectful staff
Staff knew people well and supported them patiently. Inspectors saw that privacy and dignity were respected during personal care and daily activities.
“We observed that caring relationships had developed between people and staff.” from the report
Improvements after the previous inspection
The home had addressed the three breaches found in 2016. Inspectors found better capacity records, care planning and quality monitoring.
“At this inspection, we found the provider had made the required improvements as outlined in their action plan.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you keep my relative's care plan personalised and update it when their needs change?
- 02How will you record and review mental capacity assessments and best-interest decisions for my relative?
- 03How will you make sure staff understand my relative's communication methods and health risks, including any eating or drinking guidance?
- 04How often will staff medicines competency checks and medicines audits take place?
- 05How will you support my relative to choose activities and stay in contact with relatives and friends?
This was an unannounced comprehensive inspection covering all five rating areas; the inspector observed care, spoke with relatives and staff, and reviewed three people's care records and management records. This explanation was written from the published report of 25 October 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.
What inspectors found, November 2016
Rated Requires Improvement; inspectors found safe, kind care but weaknesses in care planning, consent and quality checks.
This was an unannounced inspection on 13 September 2016. One inspector and an expert by experience visited the home, met all six residents, observed care, spoke with staff and relatives, and checked care, medicine, training and management records.
The home was rated Good for Safe and Caring. Inspectors found that people were protected from abuse, medicines were managed safely, staffing was sufficient, and staff treated people with kindness and dignity. People also received suitable food and support from health professionals.
The home Requires Improvement overall because care plans were not always personal, current or clearly linked to changing needs. Records also did not show enough detail about decisions for people who might lack capacity. Quality checks had found some problems but had not always led to prompt action.
The previous inspection in September 2014 found the provider was meeting the regulations checked. This inspection found three breaches of legal regulations. The provider was asked to send an action plan, and CQC said it would check that action was taken.
Safe medicines
Staff who gave medicines were trained and assessed as competent. Records had no gaps, medicines were stored securely and audits were carried out.
“Medicine administration records (MAR) were clearly signed with no gaps in the recordings.” from the report
Enough trained staff
The report found sufficient qualified and experienced staff, with flexible staffing for activities and appointments. Staff received supervision and training.
“There were sufficient qualified and experienced staff to meet people's needs.” from the report
Health and nutrition support
People had suitable food, drinks and snacks, and were supported to see GPs, dentists and other health professionals when needed.
“People were supported to access healthcare services.” from the report
Care plans were not current
seriousCare plans were not consistently personal or up to date. They did not always explain how staff should respond to changed needs, including a newly diagnosed sight impairment.
“They were not always reviewed and up to date in accordance with people's changing needs.” from the report
Capacity and consent records
seriousMental capacity assessments and best-interest records lacked enough detail. This affected decisions such as bed rails, sensory equipment and staff-administered medicines.
“There was an absence of sufficient systems in place to support people who lacked capacity to make their own decisions.” from the report
Cleaning and maintenance
needs fixingInspectors found that all areas needed a deep clean and that the garden needed attention. Torn cot-side padding was also awaiting replacement.
“We observed that all areas of the home were in need of a deep clean and the manager had noted that the garden also required attention.” from the report
- 01How have you made sure every resident's care plan is personal, reviewed regularly and updated when needs change?
- 02How do you record mental capacity assessments and best-interest decisions, including decisions about bed rails, sensory equipment and medicines?
- 03What action was taken after the three breaches, and what evidence can you show that the changes have been maintained?
- 04Have the deep cleaning, garden work and torn cot-side padding been completed?
- 05How are residents and their representatives involved in care planning and decisions when a resident cannot communicate verbally?
This was an unannounced inspection covering all five key questions and the overall rating, with records checked for three people's care. This explanation was written from the published report of 24 November 2016 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 13a Repton Drive
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- October 2017Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2016Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2014
Report published without a new overall rating.
- September 2013
Registered with the Care Quality Commission on 13 September 2013.
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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