CQC report explained · a residential care home
What the CQC found at Breach House
Rated Inadequate: inspectors found the home performing badly and the CQC has taken enforcement action.
What inspectors found, August 2023
Rated Requires Improvement; the home had made major progress and left special measures, but safety and leadership still needed improvement.
This was an unannounced follow-up inspection on 14 June 2023. Inspectors spoke with people living at the home, relatives and staff. They checked care and medicines records, staff recruitment, audits and the care being delivered.
The home was rated Good for effective, caring and responsive care. Inspectors found detailed care plans, kind and respectful staff, suitable support with food and healthcare, and better systems for complaints and safeguarding.
Safe and well-led were rated Requires Improvement. Inspectors found medicines were not always stored safely and some environmental risks had not been identified. New audit and monitoring systems were in place but needed more time and work to become reliable.
The previous inspection had rated the home Inadequate and placed it in special measures. The home was no longer in breach of the regulations found previously, was no longer rated Inadequate and left special measures.
Kind and respectful care
Inspectors found staff treated people with dignity and promoted privacy, choice and independence.
“The manager and staff were caring and respectful of people which ensured a person-centred approach to the people living in the home.” from the report
Detailed care planning
Care plans and risk assessments reflected people's individual needs and were reviewed regularly.
“This inspection found care plans and risk assessments were specifically detailed to people's individual needs.” from the report
Staffing improved
There were enough skilled staff on duty, and the provider was no longer relying on agency staff for additional shifts.
“This inspection found the provider had a clear staff dependency tool to determine safe staffing levels and there was a sufficient number of skilled staff on duty.” from the report
Better safeguarding
Safeguarding and whistleblowing procedures had been introduced, and staff understood their responsibilities.
“This inspection found clear safeguarding and whistleblowing procedures had been implemented.” from the report
Good healthcare support
Staff worked with GPs and district nurses and helped people access healthcare when needed.
“Staff worked closely with people's GP's and district nurses.” from the report
Medicines storage
seriousMedicines were not always stored safely. The report identified concerns about topical creams, securing the medicine trolley and temperature control in the medicines room.
“Medicines were not always stored safely.” from the report
Environmental risks
seriousSome windows did not have restrictors, some wardrobes were not securely fixed and a damaged light switch had not been reported. The manager acted during the inspection.
“Environmental risks to maintain people's safety were not always identified and mitigated.” from the report
Quality checks not fully reliable
needs fixingNew audits and monitoring systems had not yet been embedded and did not identify every medicines or environmental risk.
“New audits and quality assurance systems had been introduced but these required further development to provide sufficient oversight of the service delivery.” from the report
Management arrangements
needs fixingThere was no registered manager at the inspection. The manager later left, and the provider was recruiting a new manager.
“At the time of our inspection there was no registered manager in post.” from the report
- 01How have you fixed the medicines storage problems, including the medicine trolley and medicine room temperature?
- 02Have all window restrictors been fitted, wardrobes securely fixed and damaged fittings reported and repaired?
- 03Who is currently managing the home while you recruit a new registered manager?
- 04How do your new audits now check for medicines, environmental and other safety risks?
- 05How are you checking that staff training records are complete and accurate?
This was an unannounced follow-up inspection of the care home, covering all five key questions and checking progress after the previous Inadequate rating and breaches. This explanation was written from the published report of 11 August 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, July 2023
Rated Inadequate and placed in special measures; inspectors found people at risk of harm across all five areas.
This was an unannounced inspection over three visits in June 2022. Inspectors reviewed care, medicines and other records, observed care, spoke with people, staff, families and health professionals, and checked infection control.
Inspectors found serious problems with risk management, medicines, staffing and safeguarding. Records did not reliably show people's needs or the care they received. Some people had skin damage, missed medicines or were exposed to choking, falls or other risks.
People were not always treated with dignity or involved in their care. Care was not personalised, activities were limited, complaints were not properly handled and management had no effective system to check quality or learn from problems.
All five areas were rated Inadequate. The home remained in breach of regulations after its previous rating of Requires Improvement. It was placed in special measures, meaning CQC said it would keep the home under review and usually re-inspect within six months.
Recruitment checks
Inspectors found suitable recruitment checks for permanent staff and enough information about the background checks for agency staff.
“The provider had a recruitment system that ensured only suitable staff were employed.” from the report
Some infection controls
Inspectors were assured that staff used personal protective equipment safely and that the infection control policy was up to date.
“We were assured the provider was using PPE effectively and safely.” from the report
Serious risk management failures
seriousCare plans and risk assessments did not give staff the information needed to manage pressure sores, choking or falls. One person was given an unthickened drink despite a known choking risk.
“This exposed people to the avoidable risk of becoming unwell.” from the report
Unsafe medicines
seriousMedicines were missed and one person received three times the stated dose of a medicine. Staff did not always seek medical advice or carry out suitable checks after omissions.
“The provider had not ensured the proper and safe use of medicines.” from the report
Safeguarding and dignity
seriousUnexplained injuries were not consistently recorded or investigated. Inspectors also witnessed verbally abusive practice and found examples of people not being treated with dignity.
“Systems and processes to prevent abuse and improper treatment did not operate effectively.” from the report
Insufficient staffing
seriousPeople waited a long time for meals and staff said there were not enough staff to provide the support needed. Agency staff did not always understand people's individual risks.
“There were not sufficient numbers of suitable staff to effectively meet people's needs.” from the report
Poorly personalised care
needs fixingCare plans did not include people's preferences, interests or wishes for end of life care. There was little support to prevent isolation or take part in activities.
“There was no support for people to avoid social isolation, follow interests or take part in activities.” from the report
- 01What has changed to make sure pressure sores, choking risks and falls are assessed, recorded and managed safely?
- 02How do you now check that medicines are given as prescribed, and what happens when a dose is missed?
- 03What staffing levels and checks on agency staff are now in place to meet people's individual needs?
- 04How are people and their families involved in care planning and asked about their experience of care?
- 05What audits or other checks now identify problems with medicines, incidents, care plans and complaints?
This was an unannounced inspection prompted by concerns about staffing, risk management and management oversight; inspectors assessed all five key questions and rated each one Inadequate. This explanation was written from the published report of 11 July 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.
Every inspection of Breach House
6 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- August 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2023Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- May 2022Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- January 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- December 2013
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- April 2012
Registered with the Care Quality Commission on 20 April 2012.
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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At least 100 live-in carers within about an hour of Worcestershire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 85 can care for a couple. 9 years' experience on average.
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.