CQC report explained · a residential care home
What the CQC found at 27 Flamstead End Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that people felt safe, staff understood safeguarding, staffing was generally sufficient, recruitment was robust and medicines were managed safely. A relative reported that staffing at some early mornings might not always have kept one person safe after a fall.
- Effective?
- Good
- Staff had relevant training and supervision, and people received support with food, drink and health needs. Inspectors could not find evidence that a mental capacity assessment and best-interest decision had been completed for a bedrails condition attached to a DoLS authorisation.
- Caring?
- Good
- Staff were kind, respectful and discreet, and knew people well. Inspectors found that the cabinet holding care records could be opened without physically undoing the lock, which could put private information at risk.
- Responsive?
- Good
- Care plans were usually detailed and reviewed, and staff understood people's routines, preferences and needs. One care plan was not detailed enough, and end-of-life wishes had not been documented for people.
- Well-led?
- Requires improvement
- Management checks did not always identify shortfalls, investigations were not always robust and some incidents had not been notified to CQC. Staff found managers approachable, but meeting records did not show enough evidence of learning, staff involvement or quality improvement.
What inspectors found, February 2018
Grange Care Services Limited - 27 Flamstead End Road was rated Good overall, but inspectors found that leadership required improvement.
Inspectors made an unannounced visit on 17 January 2018. They observed care, spoke with staff, relatives and managers, and reviewed care, medicines, recruitment and quality records.
The home was rated Good for safe, effective, caring and responsive care. Inspectors found kind staff, personalised support, safe medicines arrangements, enough trained staff and appropriate help with health, food and activities.
The home was rated Requires Improvement for being well-led. Quality checks had missed problems, some investigations were not strong enough and some incidents had not been reported to CQC. There were also gaps around a DoLS condition, end-of-life planning and information security.
The overall rating was Good. This means the main areas of care met the expected standard, but the management weaknesses needed attention.
Kind and respectful staff
Inspectors saw staff treating people with kindness and protecting their dignity. Relatives also described the staff as caring.
“Staff had developed positive and caring relationships with people they clearly knew well.” from the report
Personalised support
Staff knew people's routines, preferences, backgrounds and personal circumstances. Care plans were generally detailed enough to guide individual support.
“Staff were knowledgeable about people's preferred routines, likes and dislikes, backgrounds and personal circumstances” from the report
Safe medicines and recruitment
Medicines were stored, managed and disposed of safely. Recruitment records checked by inspectors contained the required references and criminal record checks.
“There were suitable arrangements for the safe storage, management and disposal of medicines and people were supported to take their medicines by trained staff.” from the report
Health and nutrition support
People received support to eat and drink, and staff made referrals to health and social care professionals when needed.
“Appropriate referrals were made to health and social care specialists as needed and there were regular visits to the home from dieticians, opticians and chiropodists.” from the report
Management checks missed problems
needs fixingAudits did not identify several issues, including an insecure records cabinet, missing end-of-life plans and an unmet DoLS condition. A recurring infection control issue also had no clear action plan.
“The provider's quality monitoring of the service had not always identified areas of shortfall and management of the service was not always robust.” from the report
Incidents were not always reported to CQC
seriousSome incidents with potential effects on people's safety and wellbeing had not been notified to CQC. This meant CQC could not check whether the right action had been taken.
“CQC had not been notified of some incidents which meant we could not check that appropriate action had been taken.” from the report
Staffing at a busy time
seriousA relative said that staff deployment early in the morning might not always keep everyone safe while other people were being helped to prepare for day services. A person had fallen and it was unclear how long they had been on the floor.
“This has meant that the person had a fall and it was not clear how long they had been lying on the floor before staff found them.” from the report
DoLS condition not completed
seriousInspectors could not find the required mental capacity assessment and best-interest decision about bedrails. The area manager was not aware that this condition existed.
“We could not find any evidence that a mental capacity assessment or best interest meeting had been undertaken in this regard.” from the report
End-of-life plans missing
needs fixingThe home did not have end-of-life care plans or records of people's wishes in this area. The provider said this would be taken forward as an action point.
“The service did not have care plans in place in relation to people's end of life care” from the report
Private records not fully secure
needs fixingInspectors opened the cabinet containing care records without undoing the lock on three occasions. Staff knew this was possible, so private information might not always have been secure.
“This meant that people's personal and private information may not always be securely maintained.” from the report
- 01What has been done to make sure all incidents affecting safety are reported to CQC when required?
- 02How are audits now checking DoLS conditions, end-of-life plans, record security and infection control repairs?
- 03How will staffing be arranged during early mornings when several people need personal care or preparation for day services?
- 04Have end-of-life care plans and people's wishes now been discussed and recorded?
- 05What changes have been made to make staff meetings record learning, practice issues and staff involvement in improving the home?
This was an unannounced inspection of the whole service, covering all five CQC questions, including care, premises, records, staffing, medicines and management systems. This explanation was written from the published report of 6 February 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 27 Flamstead End Road
2 rated inspections over 2 years: the service has held its Good rating throughout.
- February 2018Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2014
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 6 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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