CQC report explained · a residential care home
What the CQC found at 694 Pinner 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, May 2022
Rated Good overall; inspectors found kind, person-centred care, but safe care Requires Improvement because medicines systems were not always robust.
The home supports up to eight people with learning disabilities and autistic people. Inspectors visited without warning on 30 March 2022. They spoke with people, relatives, staff and a health professional, and checked care records, medicines, recruitment and management records.
People were protected from abuse and avoidable harm. Risks were assessed, staff were trained, and care was respectful. People had choice, support to become more independent, healthy food, healthcare and opportunities to use the community.
The main shortfall was in medicines records and the process for acting on medicine alerts. Inspectors found no evidence that people received the wrong medicines, and the provider supplied evidence after the visit that improvements had been made. The overall rating stayed Good, but Safe fell from Good to Requires Improvement.
Protection from abuse
Staff understood how to recognise and report abuse. Inspectors found robust safeguarding systems and relatives said people were safe and well looked after.
“The service had robust systems and processes to ensure people who used the service were protected from harm and abuse.” from the report
Managing risks
Risks such as community access, personal care and behaviours that challenge were assessed and reviewed. Staff had relevant training and inspectors found no evidence of physical or chemical restraint.
“Risk assessments viewed were detailed and covered a wide range of potential risks such as access to the community, personal care and behaviours that challenge the service.” from the report
Personalised support
People had detailed care plans that reflected their abilities, preferences and support needs. Staff could explain how people liked to be supported.
“People who used the service had detailed person centred care plans.” from the report
Choice and independence
People were supported to make choices and develop everyday skills. They could take part in household tasks, community activities and interests such as sport and music.
“People were supported to develop skills in order to do things as independently as possible.” from the report
Food and health support
People received home-cooked food and could choose meals and when to eat. Their health needs were monitored, with support from healthcare professionals when needed.
“People were provided a home cooked, healthy and balanced diet.” from the report
Medicines records and alerts
needs fixingOne medicines care plan was not up to date, and other plans had outdated pharmacy details. Inspectors could not confirm that medicine alerts were acted on promptly, although they found no evidence that people received incorrect medicines.
“The process in place to receive and act on medicine alerts was not always robust.” from the report
Medicines policy not always followed
needs fixingStaff did not always follow the provider's medicines policy. The home did not have photographs or medicine profiles for people as required by that policy.
“However, staff members did not always follow it.” from the report
- 01How have you kept medicines care plans accurate and up to date since the inspection?
- 02How do you receive, record and act on medicine alerts, and how quickly are they checked?
- 03Do all people now have the photographs and medicine profiles required by your medicines policy?
- 04What changes were made after the inspection, and how do you check that they are still working?
- 05How do you make sure new staff recruitment checks are completed before they start work?
This was a focused inspection of Safe, Effective, Responsive and Well-led; Caring was not included and no rating was given for it. This explanation was written from the published report of 21 May 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, March 2020
694 Pinner Road rated Good; inspectors found safe, kind, person-centred care and strong support for choice and independence.
This was a planned, unannounced inspection on 6 and 10 February 2020. One inspector observed how people and staff interacted, spoke with staff, relatives and advocates, and reviewed care plans, medicines records, staff files and management records. The home supported eight people with learning disabilities and autism, many of whom had little or no verbal communication.
Inspectors found a relaxed and homely atmosphere. Staff had caring relationships with people and supported them to make choices, build independence, follow interests and maintain family, cultural and religious connections. Care plans were detailed and staff adapted support when people's needs changed.
The home was judged Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. This was the same overall rating as the previous inspection, published in September 2017. The report did not identify any breaches of regulations.
Safe medicines
Staff were trained to administer medicines and their competence was checked each year. Inspectors found that the medicines records they reviewed were complete.
“Medicines administration records (MARs) viewed had all been completed correctly and stock levels were checked regularly by the registered manager or a designated person.” from the report
Communication and independence
Staff received Makaton training and used communication passports, pictures and symbols. People were supported to make choices and learn practical skills.
“Since our last inspection the registered manager had arranged sign language training called 'Makaton' for staff” from the report
Activities and relationships
People took part in hobbies, community activities, holidays and culturally relevant activities. Staff supported friendships and contact with family.
“People who used the service engaged in a wide range of suitable, culturally relevant and stimulating activities.” from the report
Staff training
Training records showed almost all required training had been completed. Staff also received regular supervision and annual appraisals.
“Staff had access to a wide range of training and training records viewed, showed that the service had an almost 100% completion of all the training provided.” from the report
Care plans still being adapted
minorThe manager was still looking for better ways to make care plans accessible and meaningful to people. Ask what has changed since the inspection.
“The registered manager told us that he was currently looking into new ways of adapting care plans to make them more accessible and meaningful to people who used the service.” from the report
Holiday arrangements
minorThe report says people had previously missed out on good holiday deals because of delays in approving funds. The manager was discussing how to make this process easier.
“The registered manager had arranged to meet with senior leaders to discuss ways in how this could be more streamlined to enable people booking their annual holidays more easily.” from the report
- 01What changes have been made to make care plans easier for people with limited verbal communication to understand and use?
- 02What is the timetable for the planned accessible bathroom, and how are people's bathing needs supported until it is completed?
- 03What has changed in the holiday funding process since the inspection, and how do you prevent people missing suitable deals?
- 04How will you support my relative to communicate choices, including through Makaton, communication passports, pictures or symbols?
- 05How many staff would normally be supporting people on each shift, and how would this be adjusted if my relative's needs changed?
This was an unannounced inspection covering all five CQC questions, based on the previous Good rating. This explanation was written from the published report of 3 March 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.
Every inspection of 694 Pinner Road
5 rated inspections over 7 years: the service has held its Good rating throughout.
- May 2022Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2020Goodstayed GoodSafe: GoodEffective: GoodResponsive: GoodWell-led: Good
- September 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015Goodstayed GoodSafe: Good
- May 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- March 2012
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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