CQC report explained · a residential care home
What the CQC found at 25-27 Teewell Avenue
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that people were protected from abuse and avoidable harm. Risks, medicines, staffing, recruitment and infection control were managed safely, although water temperatures were slightly above the recommended level while thermostats were being replaced.
- Effective?
- Good
- This key question was not inspected during this visit. The previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. The previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. The previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found a positive, person-centred culture, effective quality monitoring and staff who understood their roles. Some decorating and repair work had been outstanding but work had started during the inspection.
What inspectors found, March 2023
25-27 Teewell Avenue was rated Good; inspectors found safe, person-centred care, with some outstanding building work.
The unannounced inspection took place on 09 February 2023 and 15 February 2023. Inspectors spoke with five people living at the home, two relatives, four staff and visiting professionals. They also observed care and checked risk, care, medicines, health and safety, maintenance and quality records.
People said they felt safe and liked living at the home. Inspectors found enough staff, safe medicines management, suitable infection control, effective risk assessments and appropriate recruitment checks. People were supported to make choices and take positive risks, such as going out and doing daily tasks independently.
The home was also judged well-led. People were involved in their care, managers monitored quality and staff felt supported. However, some painting and repair work had been outstanding, and two staff posts were vacant, although familiar bank or agency staff were covering the shortfall.
The overall rating was Good, the same as at the previous inspection published on 22 September 2017. This inspection only directly assessed Safe and Well-led. The other ratings used for the overall result were carried forward from the previous inspection.
People felt safe
People told inspectors they felt safe and liked living at the home. They had freedom to choose where and how they spent their time.
“People told us they were safe and liked living in Teewell Avenue.” from the report
Safe medicines
People received medicines as prescribed. Staff had written guidance for medicines used when needed, and only staff assessed as competent could administer them.
“People received their medicines as prescribed.” from the report
Support for independence
Staff helped people take positive risks and develop independence, including going out, preparing meals, doing laundry and taking a holiday without staff support.
“Where appropriate, staff encouraged and enabled people to take positive risks.” from the report
Positive leadership
Inspectors found a positive culture where people were involved in their care and supported to lead the life they wanted.
“There was a positive culture in the home, where people were empowered to lead the life they wanted.” from the report
Learning from incidents
The home reviewed accidents and incidents for patterns, investigated them and shared learning across the organisation.
“Where incidents had occurred, these were investigated and lessons learnt.” from the report
Water temperatures
needs fixingWater temperatures were slightly above the recommended level for preventing scalds. The manager said thermostats were being replaced and remedial work was under way.
“Water temperatures were slightly above the recommended level to prevent scalding.” from the report
Vacant staff posts
needs fixingThere were two vacant posts. Inspectors were told that regular and familiar bank or agency staff covered the shortfall while recruitment continued.
“There were two vacant posts. Assurances were provided that regular and familiar bank or agency staff were covering the shortfall and ongoing recruitment was taking place.” from the report
Outstanding decorating
minorSome skirting boards, fire doors and door frames needed painting or repair. Work had started on some areas by the second day of the inspection.
“It was noted that some skirting boards and fire doors needed painting and had been outstanding since August 2022.” from the report
Feedback to relatives
minorOne relative said they had completed surveys but rarely heard what happened as a result. The report says relatives were otherwise happy overall.
“I have completed lots of surveys but rarely get to hear what has happened in response” from the report
- 01Have the thermostats been replaced, and how are you checking that water temperatures are now safe?
- 02Are the two vacant posts still open, and who covers shifts when permanent staff are unavailable?
- 03Has all the outstanding painting and repair work to skirting boards, fire doors and door frames been completed?
- 04How do you tell people and relatives what action was taken after surveys and other feedback?
- 05What are the current ratings and findings for Effective, Caring and Responsive, which were not assessed in this inspection?
This was an unannounced focused inspection of Safe and Well-led; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection published on 22 September 2017. This explanation was written from the published report of 8 March 2023 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 2017
25-27 Teewell Avenue was rated Good; inspectors found calm, caring support, with a minor concern about condensation on patio doors.
This was an unannounced comprehensive inspection on 23 August 2017. One inspector spoke with three people, four staff and five health and social care professionals. Records, care plans, medicines, staff training, rotas and management checks were also reviewed.
The home provided accommodation and personal care for six people with mental health needs. Inspectors found people were safe, medicines were managed properly and there were enough staff. Staff understood people's needs, supported their choices and treated them with kindness and respect.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The home had also been rated Good at the inspection in June 2015, so the overall rating remained Good.
Calm atmosphere
Inspectors found the home welcoming and relaxed. People and staff were open and helpful during the visit.
“We found the service had a calm, relaxed and homely atmosphere.” from the report
Safety arrangements
There were detailed risk assessments, enough staff and systems for safe medicines, infection control and emergencies.
“People were safe. Staff understood their role and responsibilities to keep people safe from harm.” from the report
Kind and respectful care
Staff knew people's preferences and supported their dignity, choices, relationships and independence.
“People were treated with dignity and respect. Their views were sought and responded to.” from the report
Individual support
Care plans reflected people's interests and changing needs. Activities were arranged around what each person enjoyed and could manage.
“The service provided was flexible and responsive to people's individual needs and preferences.” from the report
Strong monitoring
The provider used regular audits, reviews and meetings to identify and correct shortfalls.
“Sophisticated and comprehensive systems were in place to check on the standards within the service.” from the report
Patio door condensation
minorInspectors noticed condensation on the lounge patio doors. This had been raised at the previous inspection and staff said they would raise it again with the provider.
“We noticed the patio doors from the lounge were clouded with condensation.” from the report
- 01How will you support my relative's specific mental health needs and changing care needs?
- 02How do you make sure bank staff understand each person's care plan and preferences?
- 03What progress has been made with the condensation on the lounge patio doors since this inspection?
- 04What activities would be available for someone who finds going out distressing?
- 05How would my relative and family raise a complaint or concern, and how would you respond?
This was an unannounced comprehensive inspection covering all five CQC questions, with observations, discussions with people, staff and professionals, and checks of care and management records. This explanation was written from the published report of 22 September 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.
Every inspection of 25-27 Teewell Avenue
3 rated inspections over 8 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2017Goodstayed GoodSafe: GoodWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 11 November 2010.
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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