CQC report explained · a residential care home
What the CQC found at 31 St Domingo Grove
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2022
Requires Improvement; inspectors found important progress since an Inadequate rating, but care records, staff practice and service oversight still needed improvement.
This was an unannounced follow-up inspection. Inspectors visited the home on 24 August 2022 and completed inspection activity on 30 August 2022. They spoke with people living there, relatives and staff, and checked care plans, medicines, recruitment, training and management records.
The home had improved in several areas. Inspectors found better safeguarding, safer medicines processes, improved recruitment checks, enough staff, better infection control and a cleaner environment. Physical restraint had reduced. People were more involved in their care and choices.
However, all five areas were rated Requires Improvement. Staff did not always follow plans for emotional distress. Food and fluid records were not always completed as required. Care plans contained missing or conflicting information, and systems for reviewing incidents and fixing problems were not reliable.
The previous rating was Inadequate and the home had been in Special Measures since 25 March 2022. The home is no longer Inadequate or in Special Measures, but it remains in breach of Regulation 17 and CQC will continue to monitor progress.
Cleaner environment
Inspectors found the home clean and hygienic, with improved cleaning arrangements and a more suitable environment for people's sensory and physical needs.
“The home was clean and hygienic throughout and improved cleaning schedules were in place.” from the report
Safer medicines
The home worked with the local authority medicines team. Staff administering medicines had competency checks, and records showed medicines were given as prescribed.
“Medication Administration Records (MAR) showed that people received their medicines as prescribed.” from the report
Less physical restraint
The provider had invested in training and showed a clear commitment to reducing restrictive interventions. Inspectors found a significant reduction in physical restraint since the previous inspection.
“We found a significant reduction in the use of physical restraint since the last inspection.” from the report
People involved in care
People had input into their care plans and could make choices about daily care, activities and food.
“People were supported to be involved in decisions about their care.” from the report
Enough staff
Inspectors found there were enough staff to support people, and recruitment checks had improved. However, some agency staff lacked relevant training for one person's needs.
“There were enough staff to support people.” from the report
Weak management checks
seriousIncident records did not always show effective management oversight or learning. Care plans still contained missing, inconsistent or contradictory information, and audit actions did not always have clear deadlines.
“Governance processes were not always effective at improving the quality and safety of the service.” from the report
Plans not always followed
seriousStaff did not always follow the agreed strategies for periods of emotional distress. This increased the risk that people's needs would not be met and that incidents could cause harm.
“Staff were not always following the identified control measures to effectively manage periods of emotional distress.” from the report
Incomplete food and fluid records
needs fixingFood and fluid charts did not always show that people were being supported according to their care plans or recommended diets.
“Food charts did not evidence that this was being consistently completed.” from the report
Inconsistent meaningful contact
needs fixingSome staff did not consistently engage with people in meaningful ways. The report also identified further work needed on staff culture and attitudes.
“Staff did not consistently engage with people in a meaningful way which did not always promote effective relationships with people.” from the report
Missing health passports
needs fixingNot all people had health passports. Inspectors said this created a risk that health and wellbeing needs might not be fully met when people moved between care services.
“Not all people had health passports in place.” from the report
- 01How do you check that staff follow each person's behaviour support plan during emotional distress?
- 02What has changed to make sure care plans are accurate, complete and updated when practice changes?
- 03How are food and fluid charts checked each day, especially for people with recommended diets or specific health conditions?
- 04What training do agency staff receive before supporting people who have frequent periods of emotional distress?
- 05What deadlines and checks are now used to make sure incident reviews and audit actions lead to improvements?
This was an unannounced follow-up inspection covering all five key questions, with infection prevention and control also checked as part of the Safe assessment. This explanation was written from the published report of 26 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.
What inspectors found, March 2022
Rated Inadequate and placed in special measures; inspectors found serious risks involving safety, medicines, dignity, consent and management.
This was first a targeted inspection of infection prevention and control during the coronavirus pandemic. Inspectors found concerns about the environment and infection control, so they widened it into a comprehensive inspection covering all five key questions. They visited on 11 January, 17 January and 01 February 2022, spoke with people, relatives and staff, and reviewed care plans, medicine records, staff files and management records.
The home was rated Inadequate in every area. Inspectors found serious risks from unsafe restraint, missing or outdated risk assessments, fire safety concerns, medicines errors, poor cleanliness and unsafe recruitment. They also found that people's privacy, dignity, choices and rights were not always respected. Care plans were not regularly reviewed, complaints were not properly investigated and communication information was sometimes out of date.
The home had been rated Good at the previous inspection, published on 4 September 2019. Following this inspection, CQC took urgent action, required an urgent action plan and shared concerns with external organisations. The home was placed in special measures, meaning CQC will keep it under review and normally re-inspect within six months.
Enough staff
Inspectors found a small, consistent staff team and said there were enough staff to meet people's needs.
“People were supported by a small and consistent staff team. There were enough staff to meet people's needs.” from the report
Community activities
People regularly accessed the community and took part in activities they chose.
“However, we saw that people accessed the community regularly to partake in activities of their choosing.” from the report
Family visits
People and relatives said they could visit loved ones, and records supported this.
“People and relatives told us that they could visit their loved ones. Records we viewed confirmed this.” from the report
Vaccination requirements
At the time of inspection, the home was meeting the current COVID-19 vaccination requirement for non-exempt care workers and visiting professionals.
“the service was meeting the current requirement to ensure non-exempt staff and visiting professionals were vaccinated against COVID-19.” from the report
Risk of abuse and unsafe restraint
seriousInspectors found that restraint was used frequently and sometimes as a first response. They also found that concerns about alleged abuse and unexplained bruising had not been acted on properly.
“Physical restraint was used frequently without due regard to the person's needs and safety.” from the report
Fire and other safety risks
seriousRisk assessments were missing or out of date. Inspectors found defective fire doors, no regular fire drills, an overdue fire risk assessment and evacuation plans lacking detail.
“We found multiple and significant concerns in relation to fire safety such as defective fire doors, the absence of regular fire drills, an overdue fire risk assessment” from the report
Medicines
seriousPeople did not always receive medicines as prescribed. Records had gaps and staff administering medicines had not had suitable competency checks.
“People did not always receive their medicines as prescribed. For example, one person frequently missed a regular dose of prescribed medicine.” from the report
Rights and consent
seriousRestrictive practices were used without the required legal safeguards. The home had late applications and did not always follow conditions linked to authorised restrictions.
“Restrictive practices, such as the use of physical restraint, were being used without appropriate legal authority.” from the report
Poor living conditions and dignity
seriousInspectors found a bedroom with damaged and missing items, and saw a person using the toilet with the door open while three staff were present. The provider made some improvements during the inspection, but a concern about a dummy CCTV camera remained unresolved.
“People's privacy, dignity and independence were not respected.” from the report
Weak management and complaints handling
seriousThe manager lacked oversight of incidents and care records. Complaints about missing personal items had not been recorded, investigated or answered.
“Relatives and people told us action had not been taken to address on-going complaints, despite bringing it to the attention of staff and the manager.” from the report
- 01What urgent changes have you made to the use of physical restraint, and how do you check that any restrictions are lawful, necessary and safe?
- 02How are medicines now checked, including missed doses, medicine records and staff competency?
- 03What has been done about the fire doors, fire drills, fire risk assessment and personal emergency evacuation plans?
- 04How are care plans and risk assessments reviewed with each person, their relatives and relevant health professionals?
- 05What evidence can you show that complaints are now recorded, investigated and answered?
This began as a targeted infection prevention and control inspection but was widened to a comprehensive inspection of Safe, Effective, Caring, Responsive and Well-led; all five ratings changed from Good at the 2019 inspection to Inadequate. This explanation was written from the published report of 25 March 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 31 St Domingo Grove
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- October 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2022Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- September 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 8 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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