CQC report explained · a residential care home
What the CQC found at Exmoor Drive
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2023
Exmoor Drive was rated Good; inspectors found people were safe and well supported, with minor premises repairs and recruitment challenges noted.
This was an unannounced focused inspection on 8 February 2023. Two inspectors visited the home, and an Expert by Experience gathered relatives' views by telephone. They spoke with one person, six relatives and six staff, observed care and reviewed care, recruitment, medicines and management records.
The home was rated Good for Safe and Well-led. Inspectors found that risks were assessed, medicines were managed safely, staff understood safeguarding and people were supported to make choices. Relatives were positive about the care and felt there were enough staff when they visited.
The inspection followed concerns about staffing levels, medicines and people's safety. Inspectors found no evidence that people were at risk of harm from these concerns. They noted that some shelving and kitchen cupboard doors were chipped, and that recruitment and staff retention remained an ongoing challenge.
This was a focused inspection of Safe and Well-led only. The overall Good rating remained, but the other three question ratings were carried forward from the previous inspection in 2018 rather than assessed during this visit.
Safe care planning
People's risks were assessed and reviewed. Staff had clear information about how to provide safe care.
“Risks associated with people's care were assessed and well managed. Risk assessments informed staff how to provide safe care and were regularly reviewed.” from the report
Safe medicines
Inspectors observed medicines being given sensitively. Records were complete and staff had training and competency checks.
“People's medicines were stored securely, and medicine records were fully completed and up to date.” from the report
Responsive staffing
Inspectors found staff available when people needed help, with requests answered promptly. Relatives said staffing levels had improved.
“Staff were available when people needed them and people's requests for assistance were responded to promptly.” from the report
Positive leadership
People and relatives were happy with the service and how it was managed. Staff said they felt supported and able to raise ideas.
“People and relatives were happy with the service provided and the way the service was managed.” from the report
Recruitment pressures
minorRecruitment and staff retention were still described as ongoing challenges. Vacancies were being covered by the manager, permanent staff and regular agency staff while recruitment continued.
“The registered manager described staff recruitment and retention as an ongoing challenge.” from the report
Minor premises repairs
minorSome shelving and kitchen cupboard doors were chipped. The manager said this had been reported to the maintenance team.
“As some shelving and kitchen cupboards doors were chipped.” from the report
- 01How are current staff vacancies being covered, and how often are agency staff used?
- 02Have the chipped shelving and kitchen cupboard doors now been repaired?
- 03What checks make sure medicines records remain complete and up to date?
- 04How are the improvements to eating and drinking support being monitored over time?
- 05How can people and relatives give feedback, and what changes have been made from recent feedback?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection published on 16 March 2018. This explanation was written from the published report of 4 March 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, March 2018
Rated Good; inspectors found safe, kind and personalised care, with staffing plans and activities still developing.
The inspection was unannounced and took place on 22 February 2018. One inspector spoke with people living in the home, staff, relatives and managers. They observed care and checked care records, medicines, recruitment, training, complaints and quality checks.
The inspectors found that people were safe and received their medicines properly. Staff understood people's needs, supported their choices and treated them with kindness and respect. Food, health appointments, activities and communication support were arranged around people's needs.
The home was well managed. People, relatives and staff spoke positively about the manager, and checks were used to monitor care. The overall rating was Good, and all five areas were rated Good.
The rating had not changed since the previous inspection in October 2015. The report says the effective rating improved to Good because applications had been made for authorisation where people's freedom needed to be restricted to keep them safe.
Safe medicines support
Medicines were stored securely, recorded when given and checked daily. Staff had annual checks of their competence to administer medicines.
“We saw daily medicine counts took place to identify any errors or gaps to reduce the risk to people of not receiving their medicines” from the report
Kind and respectful care
Staff knew what mattered to each person and supported choices about daily routines, clothing and personal space. They also protected people's dignity and privacy.
“We saw staff supported people in a kind and respectful manner.” from the report
Personalised support
Care plans included people's histories, interests and routines. Bedrooms were adapted and decorated to reflect individual preferences.
“We saw from people's care plans information had been gathered about their life prior to moving into the home.” from the report
Responsive communication
The home took steps to support people with communication difficulties. This included training a staff member in sign language.
“the provider had sent a staff member to learn sign language to help each person communicate.” from the report
Open management
The manager was visible and approachable. Feedback from people and relatives was used to make changes, such as arranging further puppet shows.
“We saw the registered manager had an active presence around the home talking to people living there as they went about their duties.” from the report
Staffing was still being changed
needs fixingThe home was preparing to support people with more complex needs. Recruitment was about to begin, while agency staff were being used to cover some shifts.
“The recruitment process was about to start but in the interim had supplemented the staffing levels with agency staff to cover some shifts.” from the report
Activities were under review
minorPeople had activities such as singers, puppet shows and animal experiences, but the home was considering more external entertainment and outdoor activities.
“The registered manager told us these were under review and hoped to bring in more external entertainment for people and offer more outdoor activities when the weather improved.” from the report
- 01What changes to staffing are planned for people with more complex needs, and when will recruitment be completed?
- 02How often are agency staff used, and how do you make sure they know each person's needs?
- 03Which activities are currently available, including outdoor activities and external entertainment?
- 04How are people's choices recorded when they accept or decline care?
- 05How will you keep families informed about changes to care plans, staffing or activities?
This was an unannounced inspection of the overall service, covering all five CQC questions; the previous overall rating was Good. This explanation was written from the published report of 17 March 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 Exmoor Drive
3 rated inspections over 7 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2018Goodstayed GoodSafe: GoodWell-led: Good
- December 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 January 2011.
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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At least 100 live-in carers within about an hour of Worcestershire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 85 can care for a couple. 9 years' experience on average.
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.