CQC report explained · a residential care home
What the CQC found at 26 Brookside Avenue
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Inspectors found concerns about the storage of controlled medicines, handwritten medicine records and one medicine being given after food rather than before it. They also found some outdated care plan information and that removed window restrictors had not been noticed.
- Effective?
- Good
- People's needs were assessed and staff had suitable training and guidance. Staff followed professional advice, supported healthy eating and worked within mental capacity law.
- Caring?
- Good
- Staff treated people with kindness and respect. People were supported to make choices, have privacy and develop their independence.
- Responsive?
- Good
- Care plans recorded people's preferences and staff supported activities, communication needs, relationships and complaints. People were supported to make choices about where they went and what they did.
- Well-led?
- Good
- Inspectors found clear audits, positive staff views and good oversight. However, the auditing process had not identified all the medicine, window restrictor and care plan issues.
What inspectors found, March 2020
Rated Good; inspectors found kind, person-centred care, but medicines safety and some records required improvement.
Inspectors visited on 29 January 2020. They spoke with one person, two relatives and five staff. They also observed care and checked care, medicine, recruitment and management records.
The overall rating was Good. Effective, caring, responsive and well-led care were rated Good. Inspectors found enough staff, good training, clean surroundings and support that promoted choice, independence and activities.
Safe was rated Requires Improvement. Inspectors found concerns with medicine storage and record checks. They also found some out-of-date care plan information and that removed window restrictors had not been noticed. The home said these issues would be addressed.
Kind and respectful care
Staff were observed treating people with kindness and respect. Care promoted dignity and independence.
“We saw staff treat people with kindness and respect.” from the report
Choice and independence
People were supported to make decisions about daily routines, activities, spending and going out.
“People were supported to have maximum choice and control of their lives.” from the report
Trained and sufficient staff
There were enough staff to respond quickly, and recruitment checks had been completed. Staff received training and a thorough induction.
“There were enough staff to support people. We observed that staff were available to respond to people's needs quickly.” from the report
Good partnership working
The home referred people to other professionals when needed. Staff recorded and followed professional advice.
“Professional advice was clearly documented and followed by staff.” from the report
Medicine storage and checking
seriousThe controlled drugs cabinet was not fixed to the wall. Some handwritten medicine records had no evidence of a second staff check, and one medicine was routinely given after food despite being prescribed before food.
“The controlled drugs cabinet was not secured to the wall. This cabinet is legally required to be secured due to the nature of the medicines inside.” from the report
Out-of-date care plan information
needs fixingOne care plan contained old information that contradicted current guidance. The manager said care plans were being reviewed.
“We found one care plan had old information still recorded in it. This information contradicted current guidance.” from the report
Window safety checks
needs fixingWindow restrictors had been removed by a person living there, but staff had not noticed. A risk assessment was completed after the inspection.
“However, this had not been recognised by the staff team.” from the report
- 01Have the controlled drugs cabinet and all other medicine storage arrangements now been secured correctly?
- 02How are handwritten medicine records checked by a second staff member, and how is this recorded?
- 03What was the final decision about the medicine prescribed before food, and how is the person's choice now safely managed?
- 04Have all care plans been reviewed so that old or conflicting information has been removed?
- 05How are window restrictors and other safety equipment now checked regularly?
This was a planned inspection covering all five CQC questions; inspectors spoke with one person and noted that feedback was limited in parts because of people's communication needs. This explanation was written from the published report of 13 March 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, August 2017
26 Brookside Avenue: Rated Good overall; care was safe and caring, but effective care required improvement.
Inspectors carried out an announced comprehensive inspection on 10 July 2017. One inspector spoke with the two people living there, the registered manager, two support workers and two relatives. They also observed care and checked medicines, care records, staff training, recruitment, complaints and quality checks.
The home was rated Good overall. Safe, caring, responsive and well-led were all rated Good. Effective was rated Requires Improvement because mental capacity checks were not always completed properly, guidance for periods of high anxiety lacked detail, and one health condition did not have a written care plan.
Inspectors found caring staff, enough staff on duty, person-centred support and good support with health, food and activities. The home took immediate action on the medicines issue, care plan gaps and mental capacity work during or after the inspection.
Enough trained staff
Staffing levels and skill mix were sufficient, and staff had the training and support needed for their roles.
“Relatives confirmed they felt there was sufficient staff deployed that were appropriately skilled and experienced.” from the report
Respectful care
People were treated with dignity and privacy, while staff encouraged independence rather than taking over.
“One person made their own lunch and staff supported from a distance encouraging this independence.” from the report
Personalised support
People had choices about daily life and were supported to follow their interests, attend activities and pursue education or work.
“These examples told us that staff had a person centred approach and people were happy and satisfied with the opportunities they received.” from the report
Good leadership
Staff spoke positively about the registered manager, and people and staff had opportunities to give feedback and help develop the home.
“We have regular staff meetings and staff are involved in the development of the service.” from the report
Mental capacity records
needs fixingMental capacity assessments and best-interest decisions were not always completed when people could not make specific decisions about their care. Training had been planned and the registered manager had started taking action.
“We found examples where people had signed their care plans to show they had been consulted and had given consent to how they received their care and support.” from the report
Medicine witnessing
needs fixingOne particular medicine needed to be administered and witnessed by another person, but records showed this did not always happen. The registered manager agreed to address this immediately.
“However, records showed this was not always happening.” from the report
Guidance during anxiety
needs fixingStaff knew people well, but written strategies for supporting periods of high anxiety did not contain enough specific information. The care plans were reviewed after inspectors raised this.
“However, we found that records lacked specific information and strategies to support staff effectively.” from the report
Family involvement
minorOne relative said opportunities to take part in reviews were limited and promised regular reports had not continued. The registered manager agreed to improve this.
“I've not attended a review meeting for two years, I was told when [name of family member] moved in I would get a three monthly report but I only ever received one.” from the report
- 01How do you now make sure mental capacity assessments and best-interest decisions are completed for every specific decision?
- 02What checks show that medicines needing a second person to witness them are always administered correctly?
- 03What written guidance is now available for staff when a person experiences high anxiety?
- 04Has a written care plan and risk assessment been completed for the health condition that previously had neither?
- 05How are relatives now invited to review meetings and kept updated about their family member's care?
This was an announced comprehensive inspection of all five key questions, involving two people living at the home, staff, relatives, observations and records. This explanation was written from the published report of 1 August 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 26 Brookside Avenue
3 rated inspections over 5 years: the service has held its Good rating throughout.
- March 2020Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2017Goodstayed GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- January 2012
Registered with the Care Quality Commission on 6 January 2012.
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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