CQC report explained · a residential care home
What the CQC found at 39 Hawthorne Grove
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and risks were assessed with guidance for staff. Recruitment, staffing, medicines management and infection control were all found to be safe.
- Effective?
- Good
- People's needs were assessed by health and social care professionals, and care plans gave staff detailed guidance. Staff were trained and supported, although they said they would prefer more face-to-face training.
- Caring?
- Good
- Inspectors observed kind, gentle and respectful interactions. People were offered choices, treated with dignity and encouraged to take part in everyday tasks.
- Responsive?
- Good
- Care plans were personalised and regularly reviewed with people and their families or representatives. People were supported with communication, relationships, community activities and personal interests.
- Well-led?
- Good
- The new registered manager had made significant improvements to communication, record keeping and people's quality of life. Audits and management checks gave senior leaders good oversight.
What inspectors found, April 2020
39 Hawthorne Grove was rated Good; inspectors found safe, kind and person-centred care with recent improvements in management.
This was an unannounced inspection on 10 March 2020. One inspector spoke with the three people living there, a relative, five staff and two visiting professionals. They also checked care records, staff files, medicines records and management documents.
All five areas were rated Good: safe, effective, caring, responsive and well-led. People were protected from abuse and avoidable harm. Medicines were managed safely, staff understood people's risks and needs, and the home was clean and tidy.
Inspectors saw kind and respectful support. People were offered choices, helped to stay independent and supported to use local services and activities. They found that a new registered manager had made significant improvements to communication, record keeping and people's quality of life.
Kind and respectful care
Staff knew people well and supported them calmly and gently. Inspectors saw people being treated with dignity and respect.
“We observed people being greeted and acknowledged by staff using friendly interactions.” from the report
Safe medicines and risk management
Medicines records were accurate and checked weekly. Individual and environmental risks were assessed, with clear guidance for staff.
“Medicines were administered, stored and managed safely. Peoples medicines administration records (MARs) were completed accurately.” from the report
Personalised support
Care plans described people's needs, preferences and communication methods. People and their families or representatives were involved in reviews.
“Care plans were developed using person centred language and detailed individual needs, preferences and methods of communication.” from the report
Choice and independence
People were supported to make choices, use the local community and develop everyday skills. They could move freely around the home and take part in household tasks.
“People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.” from the report
Improved leadership
Inspectors found that the new manager had improved communication, record keeping and the quality of people's lives. Staff gave positive feedback about the management style.
“The service had a new registered manager who had made significant improvements to communication, record keeping and the quality of people's lives.” from the report
Staff training format
minorMost training was delivered online. Staff said they would prefer a better balance between computer-based and face-to-face training, and this was discussed with the manager.
“Most training was via e-learning and staff told us they would prefer a more balanced mix of computer and face to face training.” from the report
Planned holidays and outings
minorThe manager was planning to reintroduce short holidays and outings after feedback from staff and relatives. Ask whether this has happened and what activities are currently available.
“The registered manager was planning to re-introduce short holidays and outings following feedback from staff and relatives.” from the report
- 01What face-to-face training is now available, alongside online training?
- 02Have short holidays and outings been reintroduced, and what activities are currently offered?
- 03How are people's communication methods and choices used in everyday care?
- 04How often are risk assessments, medicines records and care plans reviewed?
- 05What improvements has the new manager made since taking up the role, and how are these monitored?
This was an unannounced planned inspection by one inspector covering all five CQC questions, including the accommodation and care provided; no one was receiving end-of-life care at the time. This explanation was written from the published report of 8 April 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, September 2017
39 Hawthorne Grove was rated Good; inspectors found kind, personalised care, with some improvements still needed in decision-making information and weight monitoring.
This was an unannounced inspection on 23 August 2017. Inspectors observed care, spoke with the manager, staff, a relative and a commissioner, and reviewed care plans, staff records, medicines, policies and quality checks.
The home supported three people with learning disabilities. Inspectors found people were treated with kindness, supported to make choices, helped to access healthcare and activities, and cared for by staff who understood their communication and needs.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. The previous inspection had found breaches about consent and meeting people's needs. The report says the required improvements had been completed.
Kind and understanding staff
Staff knew people's likes, dislikes and communication methods. Inspectors saw positive interactions and a calm atmosphere.
“Staff knew people's needs well and there was a calm and friendly atmosphere.” from the report
Personalised care
Care plans included people's preferences, abilities and ways of communicating. They explained how staff should respond to individual wishes and distress.
“Care plans were person centred and were reviewed annually by the staff.” from the report
Safe medicines
Staff had medicines training and competency checks. Records showed medicines had been signed for, with no gaps in the MAR charts reviewed.
“MAR sheets were signed following administration and there were no gaps on the sheets reviewed.” from the report
Improvements since the previous inspection
The earlier problems about consent and meeting people's needs were addressed. Inspectors found that the provider had completed the required action.
“We found this action was completed.” from the report
Weight loss was not acted on promptly
needs fixingOne person had lost weight consistently over time, but no action had initially been taken. The manager arranged weekly weighing and screening with the district nurse after inspectors raised this.
“We noted that one person had lost weight consistently over a period of time but no action was taken.” from the report
Occasional short periods with one staff member
needs fixingA relative and the manager said there had been occasions when one staff member was on duty for a short time, usually because of unexpected absence or cover elsewhere.
“They said this happened when staff had to provide cover at other services within the organisation.” from the report
- 01How do you now identify and respond to weight loss, and how often are people's weights reviewed?
- 02What visual information or social stories do you use to help people understand important decisions?
- 03How often might only one staff member be on duty, and what arrangements protect people at those times?
- 04How are mental capacity assessments and best-interest decisions kept up to date?
- 05How are relatives involved in care plan reviews and decisions about care?
This was an unannounced inspection covering all five key questions and the overall quality of the home. This explanation was written from the published report of 19 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 39 Hawthorne Grove
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- April 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 20 December 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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