CQC report explained · a residential care home
What the CQC found at 45 Hall Green Road
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found unclear medicine instructions, medicines that had not been dated when opened, a fridge recording temperatures above the home's stated safe level, and damaged shower equipment. There were enough staff and people said they felt protected from abuse.
- Effective?
- Requires improvement
- People's needs were assessed, staff were trained and healthcare support was available. However, the home did not follow the required consent and best-interest process before releasing private information.
- Caring?
- Requires improvement
- People described staff as kind and helpful and were involved in decisions about their care. Inspectors found that private information about one person had been published without proper consent, which did not respect their privacy.
- Responsive?
- Good
- Care plans were personalised and reviewed when people's needs changed. People were supported with communication, activities, family contact and community involvement.
- Well-led?
- Requires improvement
- The manager was approachable and staff felt supported. However, quality checks repeatedly failed to find or fix problems with medicines, food storage and equipment, and inspectors found that lessons had not been learned from earlier inspections.
What inspectors found, August 2019
Overall rating Requires Improvement; inspectors found kind, personalised support but repeated medicines and management problems.
This was an unannounced planned inspection on 23 July 2019. One inspector spoke with people living in the home, observed care, spoke with a relative and six staff, and checked care, medicine, staff and management records.
The home was rated Requires Improvement overall. Safe, Effective, Caring and Well-led were all rated Requires Improvement. Responsive was rated Good. Inspectors found enough staff, kind relationships, personalised care and good support with activities and communication.
There were important shortfalls. Medicine instructions were unclear, a fridge was running too warm, and damaged shower equipment had not been identified. The home also shared private information without showing that the person had consented or that this was in their best interests. The provider sent information after the inspection about some actions taken, and CQC said it would continue to monitor the home.
Enough staff
Inspectors saw people being supported promptly. Staff had time to spend with people in activities and conversation.
“People were supported by enough staff who were available to safely support them.” from the report
Kind relationships
People spoke positively about staff, and inspectors saw staff supporting people with compassion and understanding.
“People received help and support from a kind and compassionate staff team with whom they had developed positive relationships.” from the report
Personalised care
People and those close to them were involved in care planning. Plans reflected people's needs, preferences and changes in their health.
“People, and if needed those close to them, were involved in the development and review of their own care and support plans.” from the report
Activities and communication
People took part in activities they enjoyed, kept in touch with family and friends, and were given information in ways they could understand.
“Throughout this inspection we saw people were involved in activities they enjoyed and found interesting and stimulating.” from the report
Safeguarding awareness
Staff had training about abuse and knew how to respond to concerns. People had information about how to raise issues.
“People were protected from the risks of ill-treatment and abuse as staff members had received training and knew how to recognise and respond to concerns.” from the report
Medicine instructions were unsafe
seriousInstructions for a prescribed pain-relief cream conflicted, did not clearly state how much to use, and wrongly described it as a medicine used only when needed. The cream had not been dated when opened.
“People were at risk of receiving unsafe and inconsistent care and support with their prescribed medicines.” from the report
Poor quality checks
seriousThe home's checks did not identify or act on repeated problems with medicines, fridge temperatures and damaged shower equipment. Similar medicine concerns had been found at two earlier inspections.
“The systems for learning when things go wrong was ineffective and put people at risk of receiving unsafe care and support.” from the report
Food storage risk
needs fixingFridge temperatures were repeatedly above the level stated in the home's records, but checks did not record action to keep people safe. Perishable food was destroyed after inspectors raised the issue.
“We saw temperatures were consistently recorded above the safe level indicated.” from the report
Damaged equipment
needs fixingA shower chair had extensively damaged seating, but an infection control check had recorded it as safe. The manager later said a replacement had been ordered.
“A recent check stated a shower chair cushion was in good condition, yet we saw it was extensively damaged.” from the report
Privacy and consent
seriousPrivate information about a person was published on the provider's website without a proper capacity assessment or best-interest decision. A family member who did not have recognised legal authority had been asked for permission.
“The provider failed to follow the principles of the MCA.” from the report
- 01What changes have been made to medicine instructions and checks since the inspection, and how do you know they are now safe?
- 02How are fridge temperatures checked now, and what happens immediately if they are outside the safe range?
- 03Has the damaged shower chair been replaced, and how are all equipment checks independently verified?
- 04How do you assess a person's capacity and record a best-interest decision before sharing private information?
- 05What evidence can you show that the repeated medicine problems found at earlier inspections have been resolved?
This was a planned inspection covering all five CQC questions and both the care and premises; the report compares the findings with the previous inspection published on 27 March 2017. This explanation was written from the published report of 22 August 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, March 2017
Rated Good overall, but inspectors found medicine safety and staff health checks needed improvement.
The unannounced inspection took place on 6 February 2017. One inspector spoke with people living at the home, relatives and staff. They reviewed care files, medicine records, staff recruitment and training records, complaints and safeguarding arrangements.
The home was rated Good overall. Effective, Caring, Responsive and Well-led were rated Good. Safe was rated Requires Improvement because one medicine cupboard was not secured to the wall, one short-life medicine was not date-labelled, and some staff health declarations had not been fully assessed.
Inspectors found enough staff, suitable training and good support for people's choices, health needs, privacy and independence. They also found a friendly atmosphere, personalised care and a management team that checked the service and acted when problems were found.
Kind and respectful staff
People and relatives described staff as caring. Inspectors saw staff speaking calmly and kindly, and promoting people's privacy, dignity and independence.
“We saw that the staff were kind and caring.” from the report
Personalised support
People were involved in their care plans and reviews. Staff knew their needs, risks, likes and dislikes.
“The collection and availability of this information had enabled staff to provide personalised support to people.” from the report
Activities and family contact
People were supported to take part in activities they enjoyed, use community facilities, follow their faith and maintain family relationships.
“The people here do a lot of things. Bowling, swimming, they go to the cinema and out for meals.” from the report
Training and support
Staff received induction, ongoing training, supervision and appraisals. Inspectors found staff had the knowledge needed to support people safely.
“This highlighted that staff had been given the knowledge they required to meet people's needs and to keep them safe.” from the report
Active management checks
The manager used audits and unannounced spot checks to identify problems and check whether improvements had been made.
“We saw that the registered manager carried out a further night spot check to see if improvements had been made and they had.” from the report
Medicine storage
seriousA cupboard intended for controlled medicines was not bolted to the wall. The manager said this would be put right.
“However, this inspection we saw that screws were in the cupboard to complete the task but the cupboard was not bolted to the wall.” from the report
Short-life medicine labelling
seriousOne set of eye drops had not been date-labelled when opened. This meant staff might not know when it should no longer be used.
“Without date labelling the eye drops staff would not be sure when the 28 days had past.” from the report
Checks on staff health declarations
needs fixingDeclared health conditions had not always been explored or risk assessed. Inspectors said this meant the provider had not fully assessed whether staff could carry out all parts of their roles.
“This meant that the provider had not fully assessed potential staff capability to ensure that they would be able to properly perform all of the tasks required of their role.” from the report
- 01Has the medicine cupboard now been securely bolted to the wall, and how is this checked?
- 02What system is now used to date-label short-life medicines, such as eye drops, when they are opened?
- 03How are staff health declarations assessed before employment and before staff carry out all duties?
- 04What action was taken after the medicine error identified during the inspection?
- 05How are medicine records and storage checked now, and how often are these checks reviewed?
This was an unannounced inspection of the overall service and all five CQC questions, involving seven people living at the home at the time. This explanation was written from the published report of 25 March 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 45 Hall Green Road
3 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- August 2019Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- March 2017Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- August 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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