CQC report explained · a residential care home
What the CQC found at 46 The Grove
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough suitable staff, safe medicines arrangements, suitable infection control and systems to assess and manage risks. They also found that staff understood safeguarding procedures.
- Effective?
- Good
- This question was not separately rated in this focused inspection.
- Caring?
- Good
- This question was not separately rated in this focused inspection. Inspectors did report that staff knew people well and supported their choices, independence and goals.
- Responsive?
- Good
- Care was personalised and reflected people's needs, preferences, communication methods, goals and interests. People were supported to use the local community and stay in touch with family and friends.
- Well-led?
- Good
- Inspectors found effective quality checks, visible and approachable management, staff involvement and a positive culture focused on improvement.
What inspectors found, July 2022
46 The Grove was rated Good; inspectors found safe, personalised care and stronger management, with a recent medicines error reviewed.
This was an unannounced focused inspection on 21 July 2022. Two inspectors spoke with people and staff, observed care, checked care records, medicines, audits and meetings, and partly toured the home.
The home was rated Good overall. Safe, Responsive and Well-led were rated Good. Inspectors found enough staff, safe medicines systems, personalised support, suitable communication methods and activities matched to people's interests.
The rating improved from Requires Improvement at the previous inspection in February 2021. The provider had completed an action plan, and inspectors found it was no longer breaching the regulations previously identified.
This inspection did not cover every part of care and support. It focused on whether the home was applying the principles of right support, right care and right culture.
Personal choice and independence
Staff supported people to make choices, develop everyday skills and work towards personal goals. People were supported to take positive risks and pursue their interests.
“Staff supported people to make choice and be independent.” from the report
Safe staffing and medicines
Inspectors found enough suitable staff and safe systems for storing, giving and reviewing medicines. Staff training and competency checks were in place.
“People received their medicines safely and as prescribed.” from the report
Personalised communication
Each person had a communication care plan. Staff used methods such as photographs, pictures, objects of reference and sign language.
“Staff used a variety of different methods of communication, including photographs, pictures, objects of reference and sign language.” from the report
Activities and relationships
People had individual activity plans linked to their interests and skills. They were supported to take part in community activities and keep in touch with family and friends.
“People were supported to participate in their chosen social and leisure interests on a regular basis.” from the report
Improved leadership
The home had effective audits and quality checks, and managers were described as visible and approachable. The report says improvements had been made since the previous inspection.
“There were effective systems for monitoring and improving quality at the service.” from the report
Recent medicines error
needs fixingA recent medicines error had happened before this inspection. The manager reviewed procedures, retrained staff and discussed the incident with the whole team to reduce the chance of it happening again.
“Following a recent medicines error, the registered manager had reviewed procedures and improved these to reduce the risk of a similar error reoccurring.” from the report
- 01What checks are now used to prevent another medicines error?
- 02How are people's personal goals and activity plans reviewed and updated?
- 03How will you support my relative's particular communication needs?
- 04How are people and their families involved in checking the quality of the home?
- 05What improvements from the previous inspection are still being monitored?
This was an unannounced focused inspection of the principles of right support, right care and right culture; inspectors did not look at all aspects of care and support, and only Safe, Responsive and Well-led were separately rated. This explanation was written from the published report of 29 July 2022 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, February 2021
Rated Requires Improvement; inspectors found risks in infection control, care records and management checks.
This was an unannounced focused inspection on 7 December 2020. Inspectors looked at Safe, Responsive and Well-led, including infection control. They spoke with staff and managers, reviewed records, observed care and contacted relatives and staff after the visit.
The home had supplies of protective equipment and staff had infection control training. Medicines records were accurate, and staffing was sufficient on the inspection day. Relatives said staff were approachable and kept them informed.
However, some surfaces were not cleaned properly. Risk assessments and care plans were not always reviewed on time. Activities were limited, and records were sometimes too brief or out of date. The systems used to check quality had not found these problems.
The overall rating fell from Good at the previous inspection in August 2018 to Requires Improvement. The report identified breaches of Regulation 12, Safe care and treatment, and Regulation 17, Good governance.
Medicines safety
The medicines records inspected had no gaps or errors. Medicines were stored securely, stock levels were checked and staff were trained and observed as competent.
“Medicines administration records (MAR) reviewed were completed without gaps or error.” from the report
Family contact
Relatives said staff and managers were approachable and kept them informed. Staff helped people stay in contact with relatives by telephone and online calls.
“All relatives told us the staff kept them informed of concerns and they had opportunities to phone” from the report
Safe recruitment and staffing
Recruitment records included identity checks, references, right-to-work checks and criminal record checks. Staffing on the day of the inspection was sufficient for people's needs.
“Records reviewed demonstrated staff recruitment was undertaken in a safe manner.” from the report
Infection control
seriousSome frequently touched areas were dirty or stained, including a bedroom door, dining chairs and a nearby wall. Inspectors said this created a risk of infection.
“The lack of robust cleaning arrangements and effective infection control and prevention practices meant there was a risk to people and staff from the spread of infection.” from the report
Out-of-date risk and care records
seriousSome risk assessments and care plans had not been reviewed when they should have been. This meant they might not reflect people's current needs and risks.
“We found evaluations of risk assessments were not always taking place in a timely manner.” from the report
Limited activities and family involvement
needs fixingCOVID-19 restrictions reduced activities, but some alternatives were not arranged promptly or were not varied enough. Some relatives had not been offered virtual involvement in reviews or family contact early enough.
“We found staff had supported most people to find alternative activities.” from the report
Weak quality checks
seriousManagement audits did not identify the problems with cleaning, care records, risk reviews and activities. Inspectors said the governance systems were not effective enough.
“While the provider had monitoring systems in place these had not always been effective and had failed to identify the issues we found.” from the report
- 01How do you now check that frequently touched surfaces are cleaned properly on every shift?
- 02How often are each person's risk assessments and care plans reviewed, and how do you make sure reviews are not missed?
- 03What activities are now available for each person, including activities linked to their individual interests?
- 04How are relatives involved in reviews and supported to keep in contact with family members?
- 05What action have you taken in response to the Regulation 12 and Regulation 17 breaches?
This was an unannounced focused inspection of Safe, Responsive and Well-led, including infection control; Effective and Caring were not inspected and previous ratings for those questions were carried forward. This explanation was written from the published report of 23 February 2021 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 46 The Grove
4 rated inspections over 6 years: the service has held its Good rating throughout.
- July 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2021Requires improvementdown from GoodSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2018Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Good
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 17 November 2011.
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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