CQC report explained · a residential care home
What the CQC found at 43 Station Road
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, July 2019
Rated Requires Improvement; inspectors found risks in behaviour support, medicines and oversight, with two regulations breached.
This was a focused inspection after concerns about medicines and support for behaviour that could put people at risk. The inspector visited without notice on 8 May 2019, returned on 10 May, and reviewed further information on 24 May.
The home supported four people at the time, in accommodation for up to six adults with a learning disability or autism. Inspectors found some positive care, including committed staff, clean surroundings, suitable recruitment checks and partnership working with other professionals.
However, people were not always protected from harm. There were medicines errors, incomplete incident records and gaps in risk assessments and behaviour support. Leadership had also been inconsistent, although a new management team was beginning to make improvements.
The overall rating fell from Good at the previous inspection on 30 December 2018 to Requires Improvement. Only Safe and Well-led were inspected in this visit. The other question ratings were carried forward from the earlier comprehensive inspection.
Committed staff
Staff were committed to the people living in the home. They were beginning to feel more supported by the new leadership team.
“Staff were committed to people using the service and were beginning to feel more supported by the new leadership team.” from the report
Recruitment checks
Inspectors found that recruitment checks and required information were completed before new staff started work.
“Safe and robust recruitment procedures were used when people were employed.” from the report
Clean surroundings
The communal and private areas observed by inspectors were clean and hygienic. Staff had infection control training and protective equipment.
“We observed the premises' communal and private spaces to be clean and hygienic.” from the report
Partnership working
The home worked with health and social care professionals and adapted support with a college placement to help one person access education.
“The service collaborated with a range of external professionals such as specialist consultants and occupational therapy to provide people with joined-up care and support.” from the report
Medicines errors
seriousPeople did not always receive medicines as prescribed. Inspectors found errors involving omitted medicines, wrong doses, wrong times and wrong medicines.
“There were 10 medicine errors in a seven-month period since our last inspection visit.” from the report
Behaviour-related risks
seriousBehaviour support plans and risk assessments were not always updated when people's needs changed. Crisis strategies were not always considered after incidents that could cause harm.
“Crisis intervention strategies were not considered where risk behaviours were known, or where incidents indicated this would be a proportionate response to prevent harm.” from the report
Weak oversight
seriousQuality audits did not identify several problems found by inspectors. Incident records and other management records were also incomplete.
“Systems were either not always in place or failed to assess, monitor and improve the quality of the service or mitigate the risks relating to safety of people using the service.” from the report
Unsettled leadership
needs fixingThe home had been without a registered manager or deputy manager and had changes in senior management. Staff reported low morale and limited support during this period.
“The service had inconsistent leadership due to being without a registered manager or deputy manager since December 2018 and was overseen by three different operations managers and a service improvement manager in a 12-month period.” from the report
Safeguarding training
needs fixingThe provider had not arranged face-to-face or higher-level safeguarding training for different roles. Inspectors made a recommendation for further training for the manager.
“The provider did not arrange face to face or higher levels of safeguarding training for different roles and responsibilities within the service or in accordance with local safeguarding procedures.” from the report
- 01How many medicines errors have occurred since the inspection, and what checks now make sure medicines are given at the right time and dose?
- 02How are behaviour support plans and risk assessments reviewed after incidents or changes in behaviour?
- 03How do you now record, investigate and review incidents so that repeated risks are identified and acted on?
- 04Who is currently managing the home, and what deputy or other management support is in place?
- 05What action has been completed in response to the two breached regulations, and how can we see evidence that improvements have been sustained?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 19 July 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 2018
43 Station Road was rated Good; inspectors found safe, kind and personalised care, with some training and record-keeping improvements still needed.
This was an announced comprehensive inspection on 26 September 2018. Inspectors spoke with managers, observed care, reviewed care plans and records, and contacted staff, health professionals and a relative.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines management, suitable care planning and respectful support for people with learning disabilities and autism.
The Safe rating improved from Requires Improvement at the previous inspection because recruitment checks and records had improved. Inspectors still recommended extra safeguarding training and better tracking of management actions, but found no serious risks or concerns.
Improved recruitment checks
Recruitment records for permanent staff met the required standards, addressing the main concern from the previous inspection.
“At this inspection recruitment checks and records were in line with Regulations.” from the report
Safe medicines and staffing
Inspectors found enough staff for people's needs and well-maintained medicine storage and records.
“Medicines were managed safely. Storage and records for medications including controlled drugs, were well maintained in line with requirements and best practice.” from the report
Kind and respectful care
Staff supported people at their own pace, protected privacy and dignity, and used communication methods suited to each person.
“We observed staff treated people with kindness and respect.” from the report
Personalised support
Care plans reflected people's histories, preferences and goals. Staff supported people to develop skills and take part in activities they enjoyed.
“Care assessments and plans were comprehensive, clear and person-centred.” from the report
Positive management
Inspectors received positive feedback about the management team and found an open, collaborative approach to care.
“The management team demonstrated a clear vision and passion for promoting an open, positive culture amongst the staff team.” from the report
Safeguarding training
needs fixingNot all staff had up-to-date safeguarding training, and the provider had not arranged the recommended classroom training. Inspectors recommended extra training for staff and the manager.
“We recommend that the service accesses additional internal face to face safeguarding training for staff and the manager accesses the local authority's safeguarding training, proportionate to their role.” from the report
Management records
needs fixingSome quality plans and the annual review were not available or had not been regularly updated at the visit. Inspectors recommended keeping a clearer record of actions and their completion.
“We recommend that the registered manager updates governance records on file.” from the report
Staff meetings and supervision
minorSome staff had fewer supervision sessions than the provider's policy required, and recent staff meeting minutes were not available. The home had identified this as an area for improvement.
“This was not in line with the organisations policy of four per year.” from the report
Agency staff records
minorFour agency profiles and three induction records were missing during the visit, although the manager supplied them electronically afterwards.
“The file was missing four agency profiles and three induction records.” from the report
- 01What face-to-face safeguarding training have staff and the manager completed since this inspection?
- 02How do you check that quality action plans are reviewed, completed and recorded?
- 03How often will staff receive supervision and team meetings, and how is this monitored?
- 04How many agency staff are currently used, and how do you maintain continuity and ensure their induction records are complete?
- 05How will you support a new resident's personal evacuation plan and fire drill induction?
This was an announced comprehensive inspection covering all five CQC areas, based on observations, records and feedback from managers, staff, professionals and one relative. This explanation was written from the published report of 10 November 2018 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 43 Station Road
3 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- July 2019Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2018Goodstayed GoodSafe: GoodWell-led: Good
- January 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- January 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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