CQC report explained · a residential care home
What the CQC found at 304 Southwell Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were kept safe from avoidable harm. Inspectors found suitable staffing, safe medicines management, risk assessments and infection control arrangements.
- Effective?
- Good
- People's needs were assessed before they moved in. Staff had relevant training, supported healthy eating and worked with health professionals.
- Caring?
- Good
- Staff were described as kind and caring. People were involved in decisions, treated with dignity and supported to be as independent as possible.
- Responsive?
- Good
- Care plans were personalised and regularly reviewed. People were supported with communication, relationships, interests, activities and access to the community.
- Well-led?
- Good
- The management team used regular audits and involved people, relatives and staff in how the home was run. A new manager had started on the inspection day after the previous registered manager left.
What inspectors found, March 2020
Rated Good; inspectors found safe, kind and personalised care, with a new manager due to register with CQC.
The inspection was unannounced and took place on 10 March 2020. One inspector spoke with five people, managers and seven support workers. They observed care, checked care and medicine records, staff training and recruitment checks, and reviewed quality audits.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were protected from avoidable harm, supported to make choices, treated with dignity, and helped to take part in activities and community life.
The previous inspection rating was also Good, published on 28 July 2017. A registered manager had recently left, and a new manager had started on the inspection day and intended to register with CQC.
Personalised support
The home assessed people's needs and preferences before they moved in. Care plans included personal information and were reviewed to reflect changing needs.
“People's individual and diverse needs had been identified before moving to the service and plans of care had been developed.” from the report
Kind and respectful staff
Inspectors saw staff offering choices and speaking to people in a caring way. People were involved in decisions and supported with dignity and independence.
“Support workers offered support in a relaxed and caring manner and spoke to people in a kind way.” from the report
Activities and community life
People were supported to follow their interests and take part in meaningful activities, including activities outside the home.
“People's interests and hobbies had been fully explored and people were supported to follow their interests and take part in meaningful activities of their choice.” from the report
Safe medicines practice
Medicines were given at the right times, records had no gaps, and staff training and competency checks were in place.
“Records kept showing the medicines people were supported with were appropriately completed with no gaps present.” from the report
People's involvement
People and their relatives were involved in how the home was run through meetings, surveys and regular conversations.
“People were fully involved in how the service was run.” from the report
Change of manager
minorThe registered manager had recently left. A new manager started on the inspection day and intended to register with CQC, so families may want to check how this transition is progressing.
“A new manager had started on the day of our visit and it was their intention to register with CQC.” from the report
One-to-one support incident
minorA misunderstanding between support workers meant one person briefly did not receive their planned one-to-one support. The incident was investigated and a checking system was introduced to prevent it happening again.
“one person was left without their one to one support for a short period of time.” from the report
- 01How is the change from the previous registered manager to the new manager being managed?
- 02When does the new manager expect to complete registration with CQC?
- 03What checking system is now used to make sure people receive their planned one-to-one support?
- 04How are people's care plans reviewed when their needs, goals or preferences change?
- 05How will you support my relative to continue their interests, activities and community visits?
This was an unannounced planned inspection covering all five CQC questions, with records, staffing, medicines, care delivery and quality audits reviewed. This explanation was written from the published report of 27 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, July 2017
304 Southwell Road was rated Good; inspectors found safe, caring and personalised support, with some records needing improvement.
This was an unannounced inspection on 6 June 2017. One inspector reviewed information, previous reports and notifications, and spoke with three people, two relatives, four support workers and managers. The inspector also checked care records, staff files, training records and audits.
The home supported up to eight younger adults with mental health needs and learning disabilities. Three people were living there on the inspection day. Inspectors found enough staff, safe medicines arrangements, suitable risk assessments and staff who understood people's needs.
People were treated with kindness and respect. They were involved in their care plans, supported to make choices, and helped to take part in activities and work experience. The home had systems for complaints, feedback and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. This means the inspection found the service was meeting the relevant standards at that time, although inspectors identified some records and processes that needed to be improved.
People felt safe
People told inspectors they felt safe and staff understood how to recognise and report abuse. Risk assessments were used to help people take part in activities safely.
“People told us they felt safe using the service and they were treated well by staff.” from the report
Safe medicines support
Medicines were stored securely and at the right temperature. Records were accurate, and staff had medicines training and competency checks.
“We found there were suitable arrangements that ensured medicines were stored securely, and at the required temperature when needed.” from the report
Kind and respectful staff
Inspectors saw relaxed, positive relationships. Staff respected people's privacy, dignity, communication styles and personal choices.
“People were cared for and supported by staff who respected them as individuals.” from the report
Activities and independence
People were supported to pursue hobbies, attend activities, take part in work experience and develop everyday skills such as cooking, washing and ironing.
“People were able to spend their time how they chose and pursue their interests and hobbies.” from the report
Good management oversight
People could contribute to meetings and suggestions, while staff received support and the service used audits and monitoring to review its work.
“The service was being effectively audited and monitored.” from the report
Training records were unclear
minorThe staff training matrix did not show that staff were up to date. The manager explained that the matrix was new, while a sample of individual records showed staff had completed expected training.
“The staff training matrix did not show staff were up to date with their training, however the registered manager explained this was a new matrix and had not yet been properly implemented.” from the report
Mental capacity records needed more detail
needs fixingMental capacity assessments had been completed, but the decision being assessed was not described in enough detail. The quality supervisor said this would be corrected.
“We noted that the description of the decision being assessed was not sufficiently detailed and raised this with the quality supervisor.” from the report
Some care plans were not updated
needs fixingA few care plans had not been changed after people's circumstances changed. Inspectors also found some small errors that should have been noticed during reviews.
“We identified a few occasions where a person's circumstances had changed but not all the support plans affected by this change had been updated.” from the report
One request was delayed
needs fixingOne person was still waiting for an answer to a request. Inspectors raised this with the manager, who agreed to deal with it through the complaints procedure.
“One person told us about a request they had made which they were still waiting for an answer to.” from the report
- 01How do you make sure support plans are updated quickly when a person's circumstances or needs change?
- 02How are mental capacity assessments checked to ensure the decision being assessed is described clearly and fully?
- 03How do you now monitor staff training, after the inspection found that the training matrix was not properly implemented?
- 04How are complaints and unresolved requests recorded, investigated and followed up?
- 05How will you support someone to keep building independence while managing risks in the home and community?
This was an unannounced comprehensive inspection covering all five CQC questions and included records, staff files, discussions with people and relatives, and observations during the visit. This explanation was written from the published report of 29 July 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 304 Southwell Road
2 rated inspections over 3 years: the service has held its Good rating throughout.
- March 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015
Registered with the Care Quality Commission on 1 April 2015.
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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