CQC report explained · a residential care home
What the CQC found at 16 Crompton Street
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Medicines were stored securely and given by trained staff, and there were enough staff to support people safely. Incident and accident recording was being made more detailed.
- Effective?
- Good
- Staff had relevant training, induction, supervision and appraisals. People were supported with food, health needs and access to other health and social care professionals, although consent was not always recorded in support plans.
- Caring?
- Good
- People described staff as respectful, polite and helpful. Staff supported privacy, dignity, independence and people's individual equality and diversity needs.
- Responsive?
- Good
- Support plans were personalised and reflected people's preferences, choices and risks. People knew how to raise concerns, but informal complaints were not consistently recorded.
- Well-led?
- Good
- The manager had effective audits and understood the service's responsibilities. People and staff were involved through meetings, and the manager had identified areas needing improvement.
What inspectors found, March 2019
Rated Good; inspectors found safe, kind and personalised care, with some records and home improvements still being worked on.
This was an unannounced planned inspection by two inspectors on 4 March 2019. They reviewed care records, health and safety documents, recruitment files, training, accidents, incidents, complaints and audits. They spoke with four people using the home and five staff.
The home supported six people. Inspectors found enough staff, safe medicine arrangements, suitable safeguarding procedures and good infection control. People said they felt safe and described staff as kind, respectful and helpful.
Care was personalised and people were involved in meals, choices and planning their support. Inspectors identified some gaps, including consent and complaint records, incident recording, and parts of the building needing modernisation. All five areas were rated Good.
People felt safe
People told inspectors they felt safe. Staff understood how to respond to possible abuse, and recruitment checks were completed before staff started.
“People told us they felt safe living at the home and spoke positively about the staff.” from the report
Kind and respectful staff
People said staff treated them well and respected their privacy, dignity and choices.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Personalised support
Care plans described people's preferences, interests, choices and risks. People were involved in decisions about their support and daily life.
“Support plans were personalised and detailed, accurately reflecting the choices and decisions that people could make for themselves.” from the report
Good management checks
The manager used audits covering areas such as health and safety, infection control and medicines. People and staff could contribute through meetings.
“The service had an effective system of governance.” from the report
Incident records needed strengthening
needs fixingThe manager recognised that accident and incident records needed to be more detailed so patterns in people's behaviour could be identified more clearly.
“The registered manager had identified their approach to incidents and accidents would benefit from being more detailed, they were in the process of changing this.” from the report
Consent was not always recorded
needs fixingPeople gave verbal consent, but this was not always documented in their support plans. Inspectors raised this with the manager.
“We saw that consent was not always documented in people's support plans.” from the report
Some parts of the home needed improvement
minorInspectors said the kitchen, one lounge, some windows and outside areas needed modernisation or attention. The manager had identified these issues and referred them for consideration.
“There was however, some areas of the home which required more modernisation, such as the kitchen area and one of the lounges to enable it to be more accessible for people and provide more space.” from the report
Informal complaints were not consistently recorded
needs fixingConcerns were often dealt with informally or withdrawn, so the home could not always show how it had responded or learned from them.
“These were not consistently recorded and the registered manager had already started to review this so that the service could demonstrate how they addressed concerns and any learning.” from the report
- 01What changes have been made to record consent clearly in each person's support plan?
- 02How are accidents and incidents now recorded, reviewed and used to identify patterns?
- 03What is the current position on modernising the kitchen and lounge, replacing windows and improving the outside areas?
- 04How are informal concerns and complaints recorded, followed up and used for learning?
- 05How do people living at the home continue to influence menus, communal areas and their own support plans?
This was an unannounced planned inspection covering all five key questions and the care provided, accommodation, records, staffing, medicines and management systems. This explanation was written from the published report of 29 March 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.
What inspectors found, November 2016
Rated Good overall; inspectors found kind, flexible care, but the home's leadership and safety checks needed improvement.
Inspectors visited on 10 October 2016 and gave 72 hours' notice. They spoke with two people living at the home, two staff and an area manager. They also observed care and checked care records, staff files, training records and management documents.
The home was rated Good for being safe, effective, caring and responsive. People were involved in decisions about their care, supported to stay independent and helped to access health services and activities. Staff were described as kind, respectful and knowledgeable about people's needs.
The home was rated Requires Improvement for being well-led. There was no registered manager in post, some safety and staff records were not available or complete, and monthly health and safety checks had stopped after May 2016. The home also lacked an effective system for checking medicine stocks.
Kind and respectful staff
Inspectors saw staff speaking with people compassionately and explaining what they were doing. Staff knew people's care needs and how to respond when people became anxious.
“Throughout the inspection we observed staff interacting with the people living at the service in a manner which was compassionate and caring.” from the report
Choice and independence
People had control over their daily lives and were encouraged to make choices about food, activities and support. Care was generally flexible rather than driven by a fixed timetable.
“We saw that people had choice and control over their lives and that staff responded to them expressing choice in a positive and supportive manner.” from the report
Staff training
The training records inspectors checked showed that required training was up to date. Staff also received formal supervision and appraisals.
“The training matrix provided indicated that all training required by the provider was up to date.” from the report
Care planning and activities
People took part in regular reviews of their care and helped set goals and plan activities. Their interests and comments were recorded.
“Each person had a monthly 'keyworker' review which was signed by the person and the staff member.” from the report
No registered manager
needs fixingThere was no registered manager in post at the time of the inspection. The manager was applying to become registered but was unavailable on the inspection day.
“The service did not have a registered manager in post.” from the report
Safety checks were not kept up to date
seriousMonthly health and safety checks had stopped after May 2016 because there was no manager in post. Inspectors said this may have affected people's safety.
“This meant that people's safety may have been compromised during this period.” from the report
Quality checks missed problems
needs fixingThe home's audits did not identify missing references, incomplete safety records and other record-keeping problems. Inspectors recommended a more thorough auditing system.
“However, these processes had failed to identify issues relating to the completion of essential safety checks and missing references.” from the report
Medicine stock records
needs fixingMedicines were stored and given safely, but the home did not record the starting balance of existing medicines. This meant stock could not be checked properly against administration records.
“However, the service did not have an effective system in place for monitoring stocks.” from the report
Emergency evacuation information
seriousThe emergency evacuation bag did not contain all the information needed to evacuate the building safely, including personal evacuation plans and building plans.
“However, the bag did not contain all of the important information that would be required to safely evacuate the building.” from the report
- 01Is there now a registered manager in post, and if not, who has day-to-day responsibility for the home?
- 02Have monthly health and safety checks restarted, and can you show us the completed checks since May 2016?
- 03How do you now record medicine stock balances and check them against the administration records?
- 04Has the emergency evacuation bag been updated to include each person's evacuation plan and the building plans?
- 05How does the home now check staff files and quality records so that missing references and incomplete records are found promptly?
This was an announced inspection of all five areas: Safe, Effective, Caring, Responsive and Well-led. This explanation was written from the published report of 9 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 16 Crompton Street
2 rated inspections over 2 years: the service has held its Good rating throughout.
- March 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 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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