CQC report explained · a residential care home
What the CQC found at 66 Dudley Street
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Staff understood safeguarding and people's risks, and inspectors found enough staff during the visit. Medicines were generally safe, although controlled drug records had not always been signed by two staff in the past.
- Effective?
- Good
- Staff had training and supervision, and people were supported with food, healthcare and communication. The home followed mental capacity and best-interest processes.
- Caring?
- Good
- Staff were kind and knew people well. People were offered choices, and their privacy, dignity and independence were supported.
- Responsive?
- Good
- Care records included people's preferences and communication needs. People had access to activities and outings, although relatives gave mixed feedback about opportunities to go out and about complaint updates.
- Well-led?
- Requires improvement
- Some relatives were unhappy with management communication and did not feel involved. Quality systems had missed omissions in care records and a missing up-to-date Positive Behaviour Support plan.
What inspectors found, May 2020
Rated Good overall; inspectors found kind, personalised care, but leadership, communication and record checks needed improvement.
This was an unannounced inspection on 11 March 2020. One inspector spoke with staff and four relatives, and checked care records, medicines records, staff rotas, complaints and management records. The home supported five people and could support six.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found people were protected from abuse, medicines were generally managed safely, staff supported people's health and choices, and people were treated with kindness, dignity and respect.
The Well-led rating was Requires Improvement. Relatives did not always feel involved or kept informed, and quality checks had missed some care record omissions and a missing up-to-date behaviour support plan. The plan was put in place on the day, and controlled drugs recording had improved since January 2020.
Safe care
Staff knew how to report abuse and manage risks. Inspectors found that people received their medicines as prescribed.
“Records indicated people had received their medicines as prescribed.” from the report
Kind relationships
Staff had built friendly relationships with people. People appeared relaxed with staff and were supported with warmth and respect.
“People were visibly relaxed in staff company and would seek staff out to spend time together.” from the report
Personalised support
Staff knew people's histories, interests and preferences. Care records reflected individual needs, including preferences about the gender of carers.
“Staff spoken with were able to confidently tell us about people's life history, current interests and favourite foods.” from the report
Choice and independence
People were supported to make choices about food, activities and where they spent time. Staff encouraged people to do tasks for themselves.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests” from the report
Management communication
needs fixingSome relatives did not feel informed about their loved one's wellbeing or involved in decisions. The manager had introduced a data protection policy, but acknowledged this had caused upset and was working to address it.
“Feedback from relatives indicated there were ongoing concerns around communication from management.” from the report
Record checking
needs fixingThe home's quality checks did not always identify missing information or records written in a way that did not protect people's dignity. An up-to-date behaviour support plan was also not accessible for one person until inspectors raised it.
“Systems in place to monitor quality had not always identified omissions in care records.” from the report
Staff consistency
needs fixingRelatives and staff reported high turnover and inconsistency in the care team. Inspectors found enough staff during the visit, and recruitment was continuing.
“Relative's did not always feel there were enough staff to support their loved ones and reported an inconsistency within the care team.” from the report
Complaint updates
minorSome relatives said they did not receive feedback after making complaints. Inspectors found complaints had been investigated and the manager provided details of communication with complainants.
“Relatives said they did not always receive any feedback when complaints were made.” from the report
- 01How many staff are currently working at the home, and how will you provide the assessed 2:1 support when required?
- 02How will you keep relatives informed about their family member's wellbeing and important care decisions?
- 03How do you now check care records for missing information and wording that may not protect dignity?
- 04How do you make sure each person's Positive Behaviour Support plan is current and available to staff?
- 05How are you improving access to outings, activities and transport for people who want to go out?
This was an unannounced planned inspection covering all five key questions, the premises and the care provided. This explanation was written from the published report of 28 May 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, October 2017
Rated Good; inspectors found safe, kind and personalised care, with a few records and support arrangements to improve.
This was an unannounced comprehensive inspection on 21 August 2017. One inspector and an expert by experience spoke with people living at the home, a relative, staff and managers. They reviewed care records, medicines records, staff recruitment files and quality checks.
The home supported six people with learning disabilities and associated needs. Inspectors found that people were safe, received their medicines as prescribed, and were supported by staff who understood their needs. People were offered choices, good food and access to healthcare.
Inspectors saw kind and respectful care. People were involved in their care plans, activities and daily choices. The home welcomed visitors and supported contact with family.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The overall rating stayed Good, the same as at the previous inspection in March 2015.
Safe care and staffing
Inspectors found that risks were assessed, safeguarding systems were understood and there were enough staff to support people, including when people went out.
“People received safe care and were supported to take their medicines safely and as they had been prescribed.” from the report
Kind and respectful support
Staff spoke to people gently, protected their privacy and treated them with dignity. People appeared happy and comfortable with staff.
“We observed that staff were caring towards people. They identified if people were anxious and spoke with them gently to calm.” from the report
Choice and independence
People were involved in decisions about their support, clothing, activities and where they spent their time. Staff had also identified that people should be supported to do more for themselves.
“We saw that staff offered people choices throughout the day and gave people time to make their choices.” from the report
Personalised activities and family contact
Staff knew people's likes, dislikes and preferred activities. People were supported to go shopping, attend church, take trips and keep in touch with family.
“Care plans highlighted people's likes and dislikes and their preferred community activities or in-house activities.” from the report
Visible leadership
The manager and deputy manager were available in the home, and people and relatives knew who they were. Regular audits and meetings were used to check the service.
“During the day we saw that both the registered manager and deputy manager were available and visible within the service.” from the report
Prescribed cream when out
needs fixingArrangements did not yet ensure that one person's prescribed cream could be applied at the required frequency during trips or time in the community.
“We found however, that systems were needed to ensure that one person's prescribed cream could be applied when they were on trips or out in the community.” from the report
Complaints information
minorThe complaints procedure was available, but its layout and the amount of information could make it difficult for some people to understand. The manager said it would be amended.
“However, we found due to layout and volume of information it contained it may be difficult for some people to understand.” from the report
Supporting independence
needs fixingAudits found that staff sometimes did tasks for people that they could do themselves. The home had discussed this and introduced new independence plans.
“At times staff have done tasks for people that they could do themselves.” from the report
- 01How do you make sure prescribed creams are taken and applied correctly when someone is away from the home?
- 02What changes have you made to the complaints procedure so that people can understand and use it?
- 03How do the new independence plans help people do tasks for themselves rather than staff doing them?
- 04How are people's choices recorded and reviewed when their preferences or activities change?
- 05How do you check that staffing levels remain enough when people go out into the community or staff are absent?
This was an unannounced comprehensive inspection covering all five key questions, and all five ratings were Good. This explanation was written from the published report of 3 October 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 66 Dudley Street
3 rated inspections over 5 years: the service has held its Good rating throughout.
- May 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- June 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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