CQC report explained · a residential care home
What the CQC found at Canonbury Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks to people and the environment were assessed and managed. Safeguarding, staffing, medicines and infection control arrangements were also found to be safe.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Well-led?
- Good
- Inspectors found that audits, records and governance systems had been strengthened. Staff and relatives spoke positively about the leadership and culture of the home.
What inspectors found, January 2023
Canonbury Residential Home is rated Good; inspectors found safer systems and positive leadership after the previous Requires Improvement rating.
This was an unannounced focused inspection on 13 December 2022. Two inspectors and an Expert by Experience spoke with people living there, relatives, staff and a healthcare professional. They also observed care and checked care, medicines, staff and management records.
The home was rated Good for Safe and Well-led. Inspectors found that risks in the building and environment were being assessed and monitored. Medicines were managed safely, staff understood safeguarding, and people were supported by a regular team who knew them well.
The inspection followed a previous Requires Improvement rating, when the provider had breached regulations about safe care and treatment and good governance. Inspectors found enough improvement had been made and the provider was no longer in breach.
This was a focused inspection. It only examined Safe and Well-led. The other three question ratings were carried over from the previous inspection and were not reassessed.
Improved safety checks
The home had introduced stronger checks for the building, fire safety, gas safety and legionella risks. Inspectors found that environmental risks were now being monitored.
“Risks relating to the environment were now assessed and an effective audit system was in place in relation to the safety of all areas of the home.” from the report
Safe medicines management
Medicines were administered by trained staff. Records were accurate and up to date, storage temperatures were monitored, and regular medicines checks were completed.
“Medicine Administration Record (MAR) charts were accessed online, and were accurate and up to date.” from the report
Staff knew people well
People were supported by a regular staff team familiar with their needs. Staffing was adjusted when a person's support needs changed.
“People were supported by a regular staff team who were familiar with their support requirements.” from the report
Positive leadership
Inspectors found a positive culture. Staff and relatives spoke well of the management, communication and atmosphere in the home.
“There was a positive culture in the home. Staff and relatives spoke positively about the service and the care provided to people.” from the report
People were safeguarded
Staff had safeguarding training and understood how to report concerns. People and staff felt the registered manager would act if concerns were raised.
“People were safeguarded from the risk of abuse. Staff had attended safeguarding training and understood their responsibilities around reporting concerns.” from the report
Risk assessment tools still being embedded
minorThe registered manager was still working to make the use of recognised risk assessment tools consistent with national guidance and best practice. This was a minor ongoing improvement point rather than a reported breach at this inspection.
“The registered manager was further embedding the use of recognised risk assessment tools to ensure people's safety was consistent with national guidance and best practice.” from the report
- 01How are you making sure recognised risk assessment tools are now used consistently for each person?
- 02What regular checks are carried out on fire, gas, environmental and legionella safety?
- 03How often are medicines records, storage temperatures and medicines administration checked?
- 04How will you keep families informed about changes in their relative's care and wellbeing?
- 05What evidence can you show that the improvements made after the previous inspection are being maintained?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 5 January 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, October 2022
Canonbury Residential Home was rated Requires Improvement because safety checks and management systems were not reliable, although care was kind and personalised.
This was the home’s first inspection after it was newly registered. It was unannounced and took place over 7 and 8 September 2022. Inspectors spoke with people living there, relatives, staff and professionals. They also observed care and checked care, medicines, recruitment and management records.
Inspectors found good care in several areas. People were treated with kindness, dignity and respect. Their care was personalised, they were supported to make choices, and relatives said communication was good. Staff training, food, healthcare support and activities were also viewed positively.
However, some safety risks had not been properly checked or controlled. These included fire arrangements, water safety, gas boiler maintenance and medicine storage temperatures. Audits and records were not always complete or effective. The home was rated Requires Improvement overall, with Requires Improvement ratings for Safe and Well-led, and Good ratings for Effective, Caring and Responsive.
Kind and respectful care
People described staff as kind and caring. Inspectors saw positive interactions and found that dignity, privacy and personal choices were respected.
“People appeared comfortable and content in the presence of staff members, and we saw positive and friendly interactions.” from the report
Personalised support
Care plans recorded people's likes, dislikes and preferences. Staff supported people to make choices and maintain their independence.
“People received person-centred care according to their individual needs and wishes.” from the report
Good communication
Relatives felt informed about changes in care and wellbeing. The home also worked well with healthcare professionals.
“Communication from this service provider has been consistent and informative. They share concerns and seek support as needed.” from the report
Safeguarding awareness
Staff had safeguarding training and understood how to report concerns. Inspectors saw evidence that a whistleblowing procedure had been followed effectively.
“All staff know the correct process and route in the event of a safeguarding concern.” from the report
Safety risks were not consistently controlled
seriousRisks involving legionella, fire safety and the gas boiler had not been fully assessed or managed. Inspectors said this placed people at risk of harm.
“We found no evidence that people had been harmed, however systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Medicine checks were incomplete
seriousMedicine storage temperature checks were not in place, and a recording error was not identified promptly. The manager said the auditing process would be strengthened.
“Incomplete auditing of medicines meant that a medicines error had not been identified and appropriate action had not been taken in a timely manner.” from the report
Management records and audits needed improvement
seriousGovernance systems did not give a clear enough overview of safety. Some fire evacuation records and other documents were incomplete or inaccurate.
“The provider had failed to establish and operate effective governance systems to assess, monitor and mitigate the risks to people's health, safety and welfare.” from the report
Infection control assurance was mixed
minorInspectors were only somewhat assured about preventing visitors from spreading infections, the premises' hygiene practices, outbreak planning and whether the infection policy was up to date.
“We were somewhat assured that the provider was preventing visitors from catching and spreading infections.” from the report
- 01What has been completed to control legionella risks, including regular water temperature checks?
- 02How are fire evacuation arrangements and fire equipment risks now assessed and monitored?
- 03Has the gas boiler maintenance been completed, and what checks are in place while repairs or servicing are needed?
- 04How are medicine storage temperatures and medicine recording errors now checked and reviewed?
- 05What new audits and management checks are being used to make sure safety records are complete and accurate?
This was the first planned inspection of the newly registered home and covered all five key questions, including infection prevention and control under Safe. This explanation was written from the published report of 7 October 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 Canonbury Residential Home
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- January 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
- July 2021
Registered with the Care Quality Commission on 28 July 2021.
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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38 live-in carers within about an hour of Gloucestershire
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Most charge £1,030 to £1,360 a week. 31 can care for a couple. 12 years' experience on average.
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