CQC report explained · a residential care home
What the CQC found at Blackrod House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe. Inspectors found suitable staffing, safe medicines systems, safeguarding procedures, risk assessments, infection control and checks of accidents, equipment and the building.
- Effective?
- Good
- This area was not inspected during this focused visit. The overall rating used the relevant rating from the previous comprehensive inspection.
- Caring?
- Good
- This area was not inspected during this focused visit. The overall rating used the relevant rating from the previous comprehensive inspection.
- Responsive?
- Good
- This area was not inspected during this focused visit. The overall rating used the relevant rating from the previous comprehensive inspection.
- Well-led?
- Good
- People and staff said the home was well run. Audits, meetings, questionnaires and action plans were used to monitor quality, although there was no single overarching improvement plan.
What inspectors found, June 2023
Blackrod House was rated Good; inspectors found people were safe and the home was well-led, with only a minor gap in improvement planning.
This was an unannounced, focused inspection on 24 May 2023. Inspectors visited the home, spoke with 8 people and 5 staff, and reviewed care records, risk assessments, safety records, medicines records and management information.
The home was rated Good for Safe and Well-led. People said they felt safe and were positive about the care. Inspectors found safe medicines management, suitable staffing, effective infection control and regular checks of accidents, risks, equipment and the building.
The home used audits, meetings and questionnaires to monitor quality and involve people and staff. However, there was not one overall improvement plan bringing together all actions from separate audits.
This was not a full inspection of all five areas. The overall Good rating also used ratings from the previous comprehensive inspection, published on 20 December 2017.
Safe medicines
Staff were trained and checked as competent to manage medicines. Records showed medicines were stored and given as prescribed.
“Medicines were managed and administered safely by care staff, who had received training and assessed as competent.” from the report
Staffing and recruitment
Inspectors found enough staff to meet people's needs and keep them safe. Recruitment checks included references and Disclosure and Barring Service checks.
“Enough staff were deployed to meet needs and keep people safe.” from the report
Clean and good infection control
The home was clean, staff used protective equipment appropriately and cleaning records were completed consistently.
“The home was clean with effective cleaning and infection control processes in place.” from the report
Learning from incidents
Accidents, incidents and falls were recorded, reviewed and checked for patterns so that lessons could be considered.
“Accidents, incidents and falls had been documented consistently, in line with the provider's policy.” from the report
People's views included
People and relatives were asked for their views through meetings and questionnaires. Staff also had meetings and surveys.
“People and relative's views were captured via regular meetings, as well as questionnaires.” from the report
No single improvement plan
minorActions from separate audits were used to make improvements, but they were not brought together in one overarching plan. The manager said this would be considered in future.
“An overarching improvement plan, onto which all separate actions were recorded was not currently being used.” from the report
- 01How are actions from different audits recorded and checked now that inspectors found there was no single overarching improvement plan?
- 02How do you make sure medicines given as required are effective for the person?
- 03How do you maintain staffing levels when there is sickness or annual leave, and when would agency staff be used?
- 04How are accidents, incidents and falls reviewed, and what changes have been made as a result?
- 05What were the ratings and findings for Effective, Caring and Responsive at the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led only; the other ratings used ratings from the previous comprehensive inspection published on 20 December 2017. This explanation was written from the published report of 14 June 2023 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, December 2017
Rated Good; inspectors found safe, kind and personalised care, with some concerns about staffing levels and the dining experience on the dementia unit.
This was an unannounced inspection on 07 November 2017. Inspectors spoke with people living in the home, relatives, staff and a visiting health professional. They also observed care and looked at care files, staff records, training, meetings and audits.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff during the visit, prompt responses to call bells, safe medicines systems, suitable care plans and kind, respectful interactions.
The previous inspection had found three legal breaches involving governance and person-centred care. At this inspection, inspectors said the required improvements had been made. Some people and staff said staffing could feel low at times, and inspectors noted that the dementia unit dining arrangements could be improved.
Prompt help
Inspectors saw sufficient staff during the visit and found that call bells were answered promptly. People were supported in a calm and unhurried way.
“Staff answered call bells promptly and people were supported in a calm unhurried manner by staff.” from the report
Kind and respectful care
Staff spent time talking with people, asked permission before providing support and respected privacy. People were encouraged to be as independent as possible.
“We observed staff engaging in conversation with people throughout the day. People's privacy and dignity was respected.” from the report
Personalised support
Care plans recorded people's backgrounds, preferences and routines. Inspectors saw that choices about food, clothing, bathing, bedtime and activities were followed.
“People's backgrounds, family life, preferences and interests were outlined within the files and we saw that car was provided with all these considerations in mind.” from the report
Activities and dementia support
The home offered group and individual activities, trips out and dementia-friendly spaces. Inspectors observed people taking part in activities on the inspection day.
“There were a range of activities at the home, as well as trips out.” from the report
Improved management
The three breaches found at the previous inspection had been addressed. Inspectors found regular audits, checks, staff meetings and supervision.
“At this inspection we found the required improvements had been made.” from the report
Staffing could feel low
needs fixingAlthough staffing was sufficient during the inspection, some people and staff said there were times when staffing felt low. The home did not use a dependency tool to calculate staffing needs.
“Although the majority of people we spoke to felt that there were always enough staff on duty, some people said that they felt staffing was low at times.” from the report
Dementia unit mealtimes
minorInspectors noted fewer table items and plastic cups on the dementia unit. They said condiments and napkins could have improved the dining experience with suitable supervision.
“with good supervision from staff, condiments and napkins could be used to enhance the dining experience on this unit.” from the report
Small menu writing
minorThe menu board in the residential unit was difficult to read because the writing was very small. The report did not say that this caused harm.
“There was a menu board which had the lunch time meal and evening meal displayed on a wall, but the writing on the board was very small.” from the report
- 01How do you decide the number of staff needed for each shift, given that the report said you did not use a dependency tool?
- 02What has been done to make sure staffing does not feel low at busy times?
- 03How do you make mealtimes comfortable and stimulating for people living with dementia?
- 04How are each person's food, drink and dietary preferences recorded and checked when their needs change?
- 05How can relatives see and contribute to their relative's care plan and regular reviews?
This was an unannounced comprehensive inspection covering all five key questions, including the care provided and the premises. This explanation was written from the published report of 20 December 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 Blackrod House
4 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- June 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2017Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2015
Registered with the Care Quality Commission on 1 June 2015.
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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