CQC report explained · a residential care home
What the CQC found at Breadalbane Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found that the building, equipment and fire safety arrangements were not always checked or maintained safely. They found no evidence that anyone had been harmed, but said people were placed at risk of harm.
- Effective?
- Good
- Staff had suitable training and supervision. People had appropriate food, support with their health, access to professionals and support with decision-making under the Mental Capacity Act.
- Caring?
- Good
- Staff knew people well and treated them with kindness, dignity and respect. People were involved in decisions about their care.
- Responsive?
- Good
- Care plans were mostly personalised, detailed and reviewed. Communication needs were recorded and supported, although people gave mixed feedback about activities after the activities co-ordinator left.
- Well-led?
- Requires improvement
- The home had quality checks, but they had not identified important safety and incident-monitoring problems. Inspectors found that risks were not effectively assessed, monitored or reduced.
What inspectors found, May 2022
Rated Requires Improvement; inspectors found kind, effective care, but safety checks and governance did not reliably protect people.
Inspectors visited the home unannounced on 5 April 2022. They spoke with five people and five staff, observed care, and checked care records, medicines records, recruitment files and management records. The inspection was prompted partly by concerns about infection control.
People were generally treated with kindness and respect. Inspectors rated the home Good for effective, caring and responsive care. Medicines were given as prescribed, staff were trained, people's health needs were supported, and care plans were mostly detailed and personalised.
However, the home did not always check or maintain the building and equipment safely. Problems included window restrictors, fire safety arrangements, unlocked hazardous areas, uncovered radiators, missed equipment and water safety checks, and weak reviews of accidents and incidents. Quality systems had not found these problems, so Safe and Well-led were rated Requires Improvement.
The previous inspection rating was Good under the previous provider, published on 8 January 2018. The new provider took immediate action after this inspection, including seeking specialist advice and arranging safety checks. CQC will continue to monitor the home.
Kind and respectful care
Staff had positive relationships with people and supported them with kindness, dignity and respect. People were involved in decisions about their care.
“Staff interacted with kindness and compassion throughout our inspection, treating people with dignity and respect.” from the report
Medicines managed safely
People received their medicines as prescribed. Staff had completed medicines training and competency checks, and audits were carried out.
“All staff had completed training and competency checks in the safe administration of medicines.” from the report
Health and nutrition support
People had access to a balanced diet and support for their health needs. Records showed involvement from health professionals, including speech and language therapists and dieticians.
“People were supported to maintain good health, have access to healthcare services and receive ongoing healthcare support.” from the report
Personalised care
People's needs and preferences were recorded in care plans. Staff understood how to support people in line with those plans.
“People's care needs were assessed, and clear and detailed plans of care were put in place.” from the report
Building and fire safety
seriousWindow restrictors, fire doors, escape arrangements, hazardous areas and radiator coverings were not always safe. Water safety and equipment checks, including hoists, had also not been completed.
“The physical environment posed a risk to people's health and safety.” from the report
Weak risk and incident monitoring
seriousThe home did not reliably identify patterns in accidents and incidents or learn from them. Its quality checks had not identified the safety problems found by inspectors.
“There was no effective system for analysing, investigating, and learning from incidents.” from the report
Staffing levels
needs fixingPeople and staff gave mixed views about whether there were enough staff, particularly when people had higher support needs. CQC recommended reviewing the dependency tool and staff deployment.
“People gave us mixed feedback about staffing levels.” from the report
Activities
minorPeople gave mixed feedback about activities, and the activities co-ordinator had recently left. The provider was recruiting a replacement, and CQC recommended considering current guidance on activities.
“They used to do all sorts of things in here, but they don't do them anymore” from the report
Missing mental capacity record
needs fixingOne person's record said they needed bed rails, but did not include an associated mental capacity care plan. The manager said this would be addressed immediately.
“One person's care record indicated they needed bed rails, and there was no associated mental capacity care plan.” from the report
- 01Which water safety, hoist, fire safety and window restrictor checks have now been completed, and can we see the results?
- 02What has changed in the dependency tool and staffing arrangements since the inspection, especially for shifts with people who have high dependency needs?
- 03How are accidents and incidents now analysed, investigated and used to prevent similar events?
- 04Who is responsible for activities now, and what activities are currently available to people living at the home?
- 05How are decisions about bed rails and other restrictions now recorded in mental capacity and best-interest records?
This was an unannounced inspection that considered all five CQC questions, with particular attention to infection prevention and control and safety risks; the previous Good ratings were from 2018 under the previous provider. This explanation was written from the published report of 26 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.
Every inspection of Breadalbane Residential Home
4 rated inspections over 7 years: the service has improved, from Inadequate to Requires improvement.
- May 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Breadalbane Residential Home →
- May 2021Inspected but not ratedSafe: Inspected but not rated
- January 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015Goodup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2022
Registered with the Care Quality Commission on 14 March 2022.
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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