CQC report explained · a residential care home
What the CQC found at Endsleigh Care Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments did not give enough guidance about violence and aggression, and some known risks were not recorded promptly. Inspectors also found unsafe premises and weaknesses in infection prevention and control.
- Effective?
- Good
- Staff received training and supervision, people were supported with food, drink and health needs, and the home worked with health and social care professionals. Inspectors noted that pre-admission assessments did not fully cover equality and diversity needs and training records were not up to date.
- Caring?
- Good
- People said staff were caring and respectful. Staff supported people's privacy, dignity, independence and involvement in decisions about their care.
- Responsive?
- Requires improvement
- Care plans were person-centred and people were supported with communication, activities and community access. However, complaints were not always followed through clearly and people's end of life wishes were not routinely recorded.
- Well-led?
- Requires improvement
- People and staff described an open and positive culture, and managers understood their responsibilities. However, quality checks had failed to identify several risks found by inspectors.
What inspectors found, December 2021
Rated Requires Improvement; inspectors found kind, effective care, but safety, responsiveness and leadership needed improvement.
The inspection was unannounced and took place on 4 November 2021. Two inspectors spoke with four people and four staff, observed care, and checked care records, medicines records, staff files and management records.
People generally spoke positively about the care. Inspectors found enough staff, safe medicines arrangements, suitable training, kind and respectful staff, person-centred care plans, activities and support to use health services.
However, some safety risks were not properly assessed or controlled. Dangerous objects were accessible, a bathroom lock could not be opened quickly in an emergency, and infection control checks and cleaning records were not reliable. Complaints, end of life wishes and quality checks were also not always recorded properly.
The overall rating was Requires Improvement. Effective and Caring were rated Good. Safe, Responsive and Well-led were rated Requires Improvement. Safe, Responsive and Well-led had fallen from Good at the previous inspection, published on 2 November 2018.
Enough staff
Inspectors found enough staff to support people safely. Staff did not appear rushed and recruitment checks were robust.
“There were enough staff working at the service to support people in a safe way.” from the report
Medicines
Medicines were stored securely, administration records were accurate and stock balances were checked.
“MARs we checked were accurate and up to date.” from the report
Kind and respectful care
People said staff treated them well. Inspectors saw caring and sensitive interactions and found that privacy, dignity and independence were promoted.
“People told us they were treated well by staff.” from the report
Person-centred plans
Care plans recorded people's needs and views and were reviewed as needs changed.
“Care plans were in place for people which set out their needs in a person-centred way.” from the report
Support with health and activities
The home worked with health professionals and supported people to attend activities, education, faith groups and community facilities.
“The service worked with other agencies to support people and meet their needs.” from the report
Risk information was not detailed enough
seriousRisk assessments did not explain warning signs, triggers or the actions staff should take if someone became agitated or aggressive. Some known risks were also not added promptly to care records.
“This lack of guidance potentially put staff, people and others at risk.” from the report
Unsafe parts of the building
seriousSome objects that could hurt people were accessible. A communal bathroom had a lock that staff could not open quickly from outside in an emergency.
“This meant staff would not be able to open the bathroom quickly in an emergency situation.” from the report
Infection control checks
needs fixingVisitors initially had no infection control signs or PPE at the entrance, some bathrooms lacked signs, cleaning records had gaps and infection control audits were not regular.
“Daily cleaning schedules were not being completed all the time.” from the report
Complaints were not fully tracked
needs fixingThe home had an out-of-date complaints policy during the inspection. Records did not always show what action had been taken in response to verbal complaints or that required audits had happened.
“there was no recording of actions or solutions to address verbal complaints which had been recorded.” from the report
Quality checks missed problems
seriousThe home's audits and monitoring systems did not identify several of the safety and infection control issues found by inspectors.
“Quality assurance and monitoring systems were not always effective.” from the report
End of life wishes
needs fixingThe home supported people receiving end of life care but did not routinely discuss and record their wishes.
“There were no systems in place to discuss people's end of life care needs.” from the report
- 01What changes have you made to risk assessments for violence, aggression and other known risks, and how do staff use them?
- 02What has been done to make all bathrooms and other parts of the building safe in an emergency?
- 03How do you now check cleaning, infection control signs and PPE, and how often are these checks audited?
- 04How are verbal complaints recorded, investigated and reviewed to make sure actions and outcomes are clear?
- 05How do you record each person's wishes about end of life care and make sure these are reviewed?
This was an unannounced inspection covering all five CQC questions, including both the premises and the care provided; Safe, Responsive and Well-led had deteriorated from Good since the previous inspection. This explanation was written from the published report of 11 December 2021 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, November 2018
Rated Good; inspectors found safe, kind and personalised care, with evacuation plans needing an update after fire safety works.
Inspectors made an unannounced, comprehensive visit on 10 October 2018. They observed care, spoke with people, staff and social care professionals, and checked care plans, medicines, staff records, complaints, incidents and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People told inspectors they felt safe, staff understood their needs, medicines were managed safely and people were supported with health, food, activities and independence.
The home had improved its care planning since the February 2016 inspection. People's goals and support information were now up to date. Inspectors recommended updating individual emergency evacuation plans after fire safety works, but did not report a breach of regulations.
Kind and respectful staff
Inspectors saw staff support people patiently and politely. Staff knew people's routines and respected their wish for privacy or time alone.
“We saw staff supported people with kindness and spoke with them politely.” from the report
Support for independence
People were encouraged to manage daily tasks and personal care where they could. They were also supported with education, work, volunteering and activities they chose.
“People took part in activities inside and outside the home.” from the report
Safe medicines practice
Staff who gave medicines had been trained. Inspectors found medicines records accurate and up to date, and a pharmacy audit found no issues.
“We saw that MAR charts were accurate and up to date.” from the report
Good oversight
The registered manager, deputy manager and external consultant carried out checks across the home. Staff said they felt supported and worked together.
“Checks were carried out on all areas of the home to identify any quality or safety issues and audit care plans staff training records and supervision.” from the report
Evacuation plans needed updating
needs fixingFire safety works had been completed or were planned. Inspectors recommended that each person's emergency evacuation plan should be updated after the works, so it matched the changed arrangements.
“We recommended to the registered manager that these are updated following the works.” from the report
- 01Have each person's personal emergency evacuation plan been updated since the fire safety works?
- 02What support would my relative receive with their mental health goals, daily living skills and independence?
- 03How would you keep my relative's care plan and progress goals up to date?
- 04What activities, education, work or volunteering opportunities could be included in my relative's individual activity plan?
- 05How can my relative or our family raise a complaint, and how would it be investigated?
This was an unannounced comprehensive inspection covering all five CQC questions and both the premises and the care provided; the report also compared the findings with the previous inspection in February 2016. This explanation was written from the published report of 2 November 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.
Every inspection of Endsleigh Care Limited
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- December 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- January 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- November 2012
Registered with the Care Quality Commission on 5 November 2012.
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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