CQC report explained · a residential care home
What the CQC found at Cabrini House 2 (Diagrama Healthcare)
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2019
Rated Good; inspectors found safe, kind and person-centred care, with some communication and staff continuity issues.
The inspection was unannounced and took place on 5 September 2019. One inspector spoke with people, staff, managers and relatives. They also observed care and checked care plans, medicines records, training records and management meeting notes.
The home supported seven people with learning difficulties and/or autism. Inspectors found that people were safe, treated kindly and supported to make choices, build skills and take part in activities. Medicines, risks, recruitment, food and infection control were managed safely.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. This was the same overall rating as the previous inspection, published in March 2017. The home did not use restraint, seclusion or segregation.
People felt safe
People and relatives said they felt safe. Staff understood safeguarding and how to manage risks, including risks linked to mobility, behaviour, diet and community access.
“People told us they felt safe.” from the report
Kind and respectful care
Staff knew people well, listened to them and supported their choices. People were treated with dignity and encouraged to be independent.
“People and their relatives said staff treated people with care and kindness.” from the report
Support for independence
People were supported to develop everyday skills, use the community, attend college and take part in personalised activities. A new programme aimed to improve confidence and coordination.
“People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.” from the report
Good health support
Staff helped people access doctors, dentists and opticians. Health professionals said staff acted on their recommendations and worked proactively to overcome obstacles.
“A health professional commented that staff at the home worked well with them and had taken up recommendations they made and implemented them” from the report
Communication was not always smooth
needs fixingSome relatives were not always sure that messages about arrangements reached the right staff. Inspectors also found that communication about some changes, including key workers, did not always work well.
“Most relatives said they thought communication worked well but two relatives said they were not always sure some messages reached the right staff.” from the report
Staff changes affected continuity
needs fixingTwo relatives said staff changed more frequently than they would like. The manager said the home was recruiting and trying to use the same agency staff to improve continuity.
“Two relatives said that they found the staff changed at the service more frequently than they would like as continuity was important for people.” from the report
Some care plan involvement was not recorded
minorPeople and relatives were involved in care plan reviews, but this involvement was not always written down. The home was transferring records to an electronic system to improve this.
“People's or their relative's involvement was not always recorded in the care plan reviews.” from the report
- 01How will you make sure messages about weekend arrangements reach every member of staff?
- 02What is the current staff turnover, and how do you provide continuity for people who need familiar staff?
- 03How do you record a person's or relative's involvement in care plan reviews on the electronic system?
- 04What progress has been made with the development workers supporting employment or work experience?
- 05How are the Montessori and positive behaviour support approaches used in my relative's daily support?
This was an unannounced inspection covering all five CQC questions, and the ratings for all five areas remained Good from the previous inspection. This explanation was written from the published report of 16 October 2019 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 2017
Rated Good; inspectors found safe, kind and personalised care, with a few improvements still being made.
This was an unannounced first inspection on 8 February 2017. The home was supporting four people, although it could accommodate up to seven. Inspectors spoke with people, staff, relatives and health and social care professionals. They also observed care and checked care records, staff files, medicines records and safety checks.
Inspectors found that all five areas were Good: Safe, Effective, Caring, Responsive and Well-led. People were supported by enough staff, received their medicines as prescribed and had risks assessed. Staff were trained, treated people respectfully and involved them in decisions about their care.
Care plans were personalised and included communication needs, health needs, preferences and activities. People were supported with meals, healthcare, social activities and life skills. The home had systems to monitor quality and make improvements.
Safe staffing
Inspectors found enough staff to meet people's needs. Recruitment checks were completed before staff started work.
“There were adequate numbers of staff employed and safe recruitment processes were in place.” from the report
Kind and respectful care
Staff were calm and knew people's personalities, routines and preferences. People were treated with dignity and respect.
“We found a calm and relaxed atmosphere during the inspection; people were content, clean, and looked cared for.” from the report
Personalised support
Care plans described people's communication, health, social and daily living needs. People were supported to be as independent as possible.
“The plans were personalised to people's own needs and included their dislikes and preferences for their care.” from the report
Activities and inclusion
People had different activities and opportunities to develop skills, spend time with others and take part in community life.
“People were provided with a range of suitable activities to encourage social inclusion and develop life skills.” from the report
Quality checks
The home used regular audits, handovers, meetings and feedback to identify and address issues.
“There were systems to monitor the quality of the service and make improvements.” from the report
Guidance for as-needed medicines
needs fixingGuidance for medicines given only when needed was still being put in place. This was intended to help unfamiliar staff understand when and how often these medicines should be used.
“Protocols for as required medicines were being put in place at the time of the inspection to help guide unfamiliar staff about the use and frequency of the medicines should the need arise.” from the report
Accessible menus
minorAt the inspection, the menus were written rather than pictorial. The manager later told inspectors that pictorial menus had been introduced.
“We saw that the menus displayed were written and not pictorial.” from the report
- 01Are the protocols for medicines given as required now complete, and how are staff checked on using them safely?
- 02Are pictorial menus still being used, and how are people involved in choosing meals?
- 03How often are care plans and pictorial support plans reviewed with each person and their family?
- 04How are staffing levels adjusted if a person's needs change?
- 05What activities and learning opportunities are currently available for each person?
This was an unannounced first inspection covering all five CQC questions and giving an overall rating for the home. This explanation was written from the published report of 8 March 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 Cabrini House 2 (Diagrama Healthcare)
2 rated inspections over 3 years: the service has held its Good rating throughout.
- October 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Cabrini House 2 (Diagrama Healthcare) →
- March 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Cabrini House 2 (Diagrama Healthcare) →
- April 2016
Registered with the Care Quality Commission on 29 April 2016.
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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