CQC report explained · a residential care home
What the CQC found at Cumbria House Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe and inspectors found suitable risk assessments, safe medicines systems, infection control and accident monitoring. The home had identified a need for an extra night worker and was recruiting two staff members.
- Effective?
- Good
- People's nutrition, hydration and healthcare needs were supported. Inspectors found improved food choices and well-kept food and fluid records for people at risk of malnutrition or dehydration.
- Caring?
- Good
- People and relatives described staff as kind and caring. Staff respected privacy, supported independence and involved people in decisions about their care.
- Responsive?
- Good
- Care plans reflected people's needs, interests, histories, preferences and cultural or religious needs. Activities were available, and people who preferred to spend time alone had this respected.
- Well-led?
- Good
- Inspectors found detailed audits, action plans and monthly governance meetings. People, relatives and staff were asked for their views and found the management approachable.
What inspectors found, August 2018
Rated Good; inspectors found kind, personalised care and improvements since the previous inspection, with night staffing still being increased.
The inspection was unannounced and took place on 1 August 2018. The inspectors spoke with people living in the home, relatives, staff and a healthcare professional. They observed care and checked care plans, medicines, staff records, training, staffing, complaints and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were protected from abuse, medicines were managed safely, care was personalised and staff treated people with kindness and respect.
The home had improved from Requires Improvement at the previous inspection in July 2017. The earlier problem with person-centred food and support had been addressed. The home had also improved its checks and monthly governance meetings, although it was recruiting extra night staff and developing better records for informal complaints.
Improved food and drink support
The home had made the required improvements after the previous inspection. People had more choice at mealtimes, and food and fluid intake was recorded when needed.
“People were now complimentary about the food and snacks available.” from the report
Safe medicines practice
Medicines were ordered, stored, administered and recorded appropriately. Staff were trained and their competence was checked regularly.
“The administration of people's medicines were managed well, keeping people safe from the risks associated with prescribed medicines.” from the report
Kind and respectful staff
People and relatives were positive about staff. Inspectors saw staff speaking respectfully, protecting privacy and helping people remain as independent as possible.
“There was clear evidence of the caring approach of staff.” from the report
Personalised care
Care plans included people's interests, life history, preferences, health needs and cultural or religious needs. Activities were offered, but personal choices not to join in were respected.
“Care plans took a holistic approach to people's care, providing staff with information individual to each person.” from the report
Stronger oversight
The home had a wide range of audits and had introduced a formal monthly governance meeting. Actions were assigned and checked when completed.
“A comprehensive range of quality auditing processes were in place to check the safety and quality of the service provided.” from the report
Night staffing was still being increased
needs fixingThe home had identified that night-time needs were increasing and was recruiting two additional staff members. One person said staffing had been short for a while.
“They had recently identified that due to increasing need through the night, an extra member of night staff was required.” from the report
Informal complaints records were being developed
minorNo formal complaints had been made, but the home was still expanding its system to capture all small concerns and verbal complaints consistently.
“They were in the process of expanding this to ensure all small 'niggles' and verbal complaints would be captured.” from the report
- 01How many staff are scheduled to work at night now, and was the planned recruitment of two night staff completed?
- 02How do you record and review informal complaints, verbal complaints and small concerns?
- 03How are food and fluid records used when someone is at risk of malnutrition or dehydration?
- 04How often are care plans reviewed, and how are families involved when a person's needs change?
- 05How are people's end-of-life wishes recorded and shared with staff and relatives?
This was an unannounced inspection covering all five CQC questions, with care, records, staffing, medicines, activities, complaints and management systems examined. This explanation was written from the published report of 22 August 2018 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, September 2017
Rated Requires Improvement; inspectors found safe, kind and responsive care, but food arrangements and quality checks were not consistently good.
This was an unannounced inspection on 5 July 2017. Inspectors spoke with 10 people, five relatives, staff and health professionals. They observed care and checked care plans, medicines, staffing, training, accidents and quality records.
People generally said they felt safe and were treated kindly. Inspectors found enough staff, safe medicine arrangements, suitable recruitment checks, personalised care plans and good access to health professionals. People were supported to make choices and keep in touch with relatives.
The main shortfall was food. People's preferences and dietary needs were not always followed, and views about food quality were mixed. The provider also needed to improve how it checked the service, including the depth of provider visits.
The overall rating was Requires Improvement. Safe, caring and responsive were rated Good. Effective and well-led were rated Requires Improvement. The report says problems identified at the previous inspection had been addressed, but one regulation was breached at this inspection.
Kind and respectful staff
People and relatives spoke positively about staff. Inspectors saw staff treating people with dignity and using a quiet, kind manner.
“We observed staff speaking with people in a quiet, kind manner using peoples chosen names in a respectful way.” from the report
Safe medicines and staffing
The earlier medicines problems had been addressed. Inspectors found enough staff and safer systems for storing, recording and administering medicines.
“Medicines when received were appropriately booked in. Changes to administration were clearly signed and dated on medicine administration records.” from the report
Personalised care
Care plans included people's history, routines, needs and preferred support. People and relatives were involved in planning and reviewing care.
“Care plans reflected people's assessed needs and how they preferred these to be supported by staff.” from the report
Staff training and support
New staff received an induction and staff had regular training, supervision and appraisals. Staff could also receive specialist training for people's needs.
“Staff received regular supervision and appraisal of their performance and development.” from the report
Food did not always meet needs
seriousThe report found that people's food preferences and dietary requirements were not always followed in a person-centred way. One person was given food that was difficult to eat, and another received a larger portion than requested.
“The inspection highlighted that meeting people's preferences and requirements around the food they received and how this was delivered was not always person centred; this is a breach of Regulation 9 (1) (a) (b) (c) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Provider checks needed more detail
needs fixingThe range of checks had improved, but provider visits focused mainly on the building. Records did not clearly show what was reviewed, what shortfalls were found or what action was required.
“Details of what documentation they may have looked at during their visit was also not recorded and whether they had identified any shortfalls and action to be taken.” from the report
Fire drill attendance
needs fixingTwo night staff had not yet attended a fire drill. Inspectors recommended monitoring attendance and checking that all staff could use evacuation equipment safely.
“records of staff attending had only recently been kept but showed that two night staff were still to attend a drill” from the report
- 01What changes have you made to ensure each person's food preferences, allergies and required food texture are followed at every meal?
- 02How do you check that people receive the portion sizes and food choices they request?
- 03How do you now record what the provider checks during visits and how actions are followed through?
- 04Have all staff, including night staff, attended fire drills and demonstrated that they can use evacuation equipment safely?
- 05How do key workers make sure care records contain enough detail about changes in a person's needs and daily wellbeing?
This was an unannounced inspection covering all five CQC questions, including care, staffing, medicines, records, the building and quality monitoring. This explanation was written from the published report of 2 September 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 Cumbria House Care Home
3 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- August 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2017Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 November 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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