CQC report explained · a residential care home
What the CQC found at Coniston House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about testing, protective equipment, social distancing, admissions and visits. They were only somewhat assured about some premises arrangements, infection-outbreak controls and records of vaccination checks for visiting professionals.
- Effective?
- Good
- This question was not inspected or rated in this targeted inspection.
- Caring?
- Good
- This question was not inspected or rated in this targeted inspection.
- Responsive?
- Good
- This question was not inspected or rated in this targeted inspection.
- Well-led?
- Requires improvement
- This question was not inspected or rated in this targeted inspection.
What inspectors found, February 2022
Inspected but not rated; inspectors found good infection-control practice, with some repairs and record-keeping still needed.
This was an unannounced targeted inspection on 13 January 2022. Inspectors looked mainly at infection prevention and control, visiting arrangements, and whether staff pressures linked to COVID-19 affected care. They also spoke with three relatives by telephone.
Staff were seen using and changing protective equipment correctly. The home was using lateral flow and PCR testing, and visitors were allowed subject to testing, temperature checks, protective equipment and social distancing. Relatives and staff said there were enough staff to meet people's needs.
Inspectors were only somewhat assured about some areas. Repairs to the laundry and a shower room floor were still due, staff belongings needed a safe storage area, and checks on visiting professionals' vaccination status needed a clearer record.
The service was inspected but not rated. This means the inspection does not provide a Good, Requires improvement or Inadequate rating for the service or its questions.
Protective equipment and testing
Staff were observed using protective equipment correctly. The home was also carrying out lateral flow and PCR testing to reduce the risk of infections going undetected.
“Staff were observed wearing, regularly changing and disposing of personal protective equipment (PPE) correctly to reduce the risk of infection.” from the report
Staffing and family contact
Staff and relatives said there were enough staff to meet people's needs. Relatives also described regular communication and said visiting was possible by appointment.
“Staff are marvellous, excellent and have gone above and beyond their call of duty.” from the report
Visitor arrangements
Visitors were welcomed with testing, temperature checks, protective equipment and social distancing. The visiting policy was reviewed as government guidance changed.
“Visitors to the service were welcome, subject to a negative lateral flow test, normal temperature and adherence to wearing the correct PPE and social distancing.” from the report
Outstanding repairs
needs fixingThe laundry needed improvements so its walls and equipment could be cleaned effectively. A shower room floor covering had a rip and was due to be replaced.
“The laundry room was due for improvements to ensure the walls and equipment could be effectively cleansed and a shower room floor was due to be replaced due to a rip in the floor covering.” from the report
Storage of staff belongings
needs fixingStaff coats and bags had been seen in several places. The manager agreed to provide a safe storage space.
“The registered manager agreed to ensure a safe space would be provided for staff possessions, such as coats and bags, that were seen in several places.” from the report
Checks on visiting professionals
needs fixingThe home was only somewhat meeting the requirement to check vaccination status for non-exempt staff and visiting professionals. Inspectors said an entry log was needed to prompt checks and keep a record.
“The registered manager agreed that a log on entry of checks of visiting professionals would prompt staff to seek assurance and keep a record to protect people.” from the report
- 01Have the laundry improvements and shower room floor replacement now been completed?
- 02Where are staff coats and bags stored, and how do you prevent belongings being left in other areas?
- 03How do you record vaccination checks for visiting professionals before they enter the home?
- 04What infection-control checks are carried out during an outbreak or when staffing is affected by COVID-19?
- 05How will visiting arrangements work now, and what checks are required for visitors?
This was an unannounced targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated and the other questions were not assessed. This explanation was written from the published report of 5 February 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.
What inspectors found, February 2020
Rated Good overall; inspectors found safe, kind and responsive care, but the home was Requires Improvement in well-led.
This was an unannounced inspection on 31 January 2020. One inspector spoke with five people and eight staff, observed care and interactions, and reviewed care, medicines, recruitment, training and management records.
Inspectors found people were safe, their health and dietary needs were met, and staff were caring and respectful. People received personalised support, took part in activities and had their complaints addressed.
The main weakness was management oversight. Audits and records did not give a clear enough picture of problems, actions or improvements. The overall rating stayed Good, but the well-led rating fell from Good to Requires Improvement.
Safe care and staffing
Risks were assessed and staff were guided on how to reduce them. Inspectors found enough staff and safe recruitment checks.
“There were enough staff to meet people's needs, this was confirmed in staff rotas and discussions with staff.” from the report
Kind and respectful staff
Staff knew people well and treated them with compassion. Inspectors saw people being supported in ways that protected their dignity and encouraged independence.
“Staff were extremely caring in their interactions with people.” from the report
Food and activities
People had choices about food and received support for particular dietary needs. They could choose from group activities, outings and one-to-one social support.
“There was a range of social activities people could choose to participate in.” from the report
Personalised support
Care records included people's preferences, communication needs and choices about how they wanted to be cared for.
“People's preferences about how they wanted to be cared for were documented in their care records.” from the report
Weak management checks
needs fixingAudits were often tick-box records and did not clearly show what had been reviewed, what action was needed or whether improvements were completed.
“The governance systems in place, including the provider's and the registered manager's audits and assessments of the service were not robust enough.” from the report
Care plans not kept current
seriousReview sheets recorded changes in people's needs, but the main care plans had not always been updated. Inspectors said this could make it difficult to identify current needs and could lead to inappropriate care.
“This made it difficult to identify the person's current needs and put them at risk of receiving inappropriate care.” from the report
Limited learning from incidents
needs fixingThe home recorded accidents, falls and incidents but did not analyse them for possible patterns or formally record how learning was used to improve care.
“There was no formal system in place to show how lessons had been learned overall and how these were being used to drive ongoing improvement.” from the report
Oral health records
needs fixingRecords showed that mouth care was provided, but there was no assessment or care plan covering people's specific oral health needs. The home said this was addressed after the inspection.
“There was no assessment or care plan to ensure people's specific oral health needs were being met.” from the report
Induction records
minorNew staff had shadow shifts, but these were not documented or assessed. This meant possible extra support needs might not be clearly identified.
“However, the shadow shifts were not documented or assessed, such as showing feedback received from the inductee and their colleague.” from the report
- 01How do you now check that care plans are updated promptly when people's needs change?
- 02What assessment and care plan is now used for each person's specific oral health needs?
- 03How do you analyse accidents, falls and incidents, and show what learning has led to improvements?
- 04How do your audits now record which care plans and other areas were checked, the actions required and whether those actions were completed?
- 05How are new staff's shadow shifts documented and assessed, and how are any extra support needs followed up?
This was an unannounced inspection covering all five CQC questions; the overall rating remained Good, while the well-led rating fell from Good to Requires Improvement. This explanation was written from the published report of 26 February 2020 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 Coniston House
3 rated inspections over 5 years: the service has held its Good rating throughout.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- February 2020Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 2 December 2010.
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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