CQC report explained · a residential care home
What the CQC found at Honeysuckle Cottage
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were not always protected from avoidable harm. Risk assessments and care plans were not always accurate, medicines were not always given at the right times, and uncovered radiators created a possible burns risk.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its previous rating was carried forward to help calculate the overall rating.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its previous rating was carried forward to help calculate the overall rating.
- Responsive?
- Requires improvement
- Care, activities and communication support were not always tailored to people's needs, preferences and wishes. Care plan reviews did not always involve people, relatives or professionals.
- Well-led?
- Requires improvement
- Management and quality checks did not reliably identify or address risks. The manager was overseeing multiple services, and the home was not consistently learning or improving.
What inspectors found, January 2024
Honeysuckle Cottage is rated Requires Improvement; inspectors found risks, medicines and care planning were not always managed safely or personally.
This was an unannounced focused inspection. Two inspectors visited on two occasions, spoke with one person, a relative and five staff, and checked care, medicine and management records.
The home was not always safe. Risk assessments and care plans did not always reflect people's current needs. Uncovered radiators, unsafe medicine timings, unsuitable meals for people with diabetes and an unassessed choking risk were identified.
People were supported by staff who knew them, and the home was clean. However, activities, communication support, care reviews and end of life information were not always personalised. Management checks did not reliably find or fix these problems.
The overall rating is Requires Improvement. Safe and Responsive fell from Good at the previous inspection, while Well-led remained Requires Improvement. The other questions were not inspected and their previous ratings were used to calculate the overall rating.
Staff understood safeguarding
Staff had training and knew how to recognise and report abuse. Safeguarding concerns were recorded and referred to the local authority.
“Staff received training and were knowledgeable about safeguarding and how to recognise and report concerns.” from the report
Clean environment
The home was clean and hygienic. Staff followed cleaning schedules and used protective equipment safely.
“Staff were using Personal Protective Equipment (PPE) effectively and safely.” from the report
Staff knew people well
Staff knew the people living at the home and could respond to their needs through verbal communication.
“We observed staff interacting with people using the service, staff knew the people well and were able to respond to their needs through verbal communication.” from the report
Complaints process
There was an accessible complaints process. Staff and relatives said they felt able to raise concerns.
“Staff and relatives said they felt confident in raising concerns.” from the report
Risks and medicines
seriousRisk assessments and care plans did not always contain enough accurate information. Time-specific medicines were not always given at the correct times, and people were at risk from other unassessed hazards.
“Medicines which were prescribed to be given 'time specific', were not always administered at the correct times.” from the report
Uncovered radiators
seriousAll radiators were uncovered. Inspectors were not satisfied that the home's touch checks were enough to prevent possible burns.
“People were not protected from avoidable harm. Radiators were uncovered and even though the service had 'touch tests' in place, we were concerned whether these were adequate to mitigate the risk of potential burns to people.” from the report
Care was not always personal
needs fixingActivities, goals, communication support and care reviews did not always reflect people's needs, wishes or preferences. Some goals had not been updated since April 2023.
“Activities were not always personalised and wishes were not explored.” from the report
Weak management checks
seriousQuality systems were in place but did not work effectively. They failed to identify or address concerns about risks, care plans, capacity assessments and medicines.
“The manager's reviews of care plans and risk management plans had not been effective and failed to identify and address concerns we had found during the inspection, this placed people at risk of harm.” from the report
- 01What has been done to cover or otherwise make the radiators safe, and how is this checked?
- 02How are time-specific medicines now recorded and checked to ensure they are given at the prescribed times?
- 03How have care plans and risk assessments been updated to reflect each person's current needs?
- 04What support is now available from dietitians or the Speech and Language Team for diabetes, weight management and choking risks?
- 05How are people and their relatives now involved in care reviews, goals, activities and communication planning?
This was a focused inspection of Safe, Responsive and Well-led only; the other question ratings were carried over from the previous inspection in 2017. This explanation was written from the published report of 12 January 2024 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, July 2017
Honeysuckle Cottage was rated Good overall; care was safe, effective, kind and responsive, but management needed improvement.
Inspectors visited on 2 June 2017. The visit was announced in advance. They spoke with people living in the home, a relative, staff and managers. They observed care and checked medicines, care records, recruitment, training, maintenance and quality checks.
They found enough staff, safe medicines arrangements and plans to manage risks. People received support suited to their needs and choices. Staff were described as friendly, respectful and knowledgeable. People were supported with health appointments, activities, independence and social contacts.
The main weakness was management. There had been no registered manager for over 18 months, with several manager changes. The home was rated Good for Safe, Effective, Caring and Responsive, but Requires Improvement for Well-led. The overall rating was Good.
At the previous inspection in June 2016, the provider breached a safety regulation about medicines and environmental risks. Inspectors found that these improvements had been made, so the provider was no longer in breach of that regulation.
Safe medicines
Inspectors found that medicines were given as prescribed, with suitable storage, records and stock checks.
“People's medicine administration record (MAR) charts showed that people received their medicines as prescribed.” from the report
Kind and respectful staff
Staff had good relationships with people and supported their privacy, dignity and choices.
“We saw and heard staff interact with people in a caring, kind and friendly manner, whilst ensuring that professional boundaries were maintained.” from the report
Personalised support
Care records included people's preferences and staff understood how to support their individual needs and emotions.
“People's care records reflected their views and preferences about how they wished to be supported and how they liked to live their life.” from the report
Good quality checks
The provider used audits to identify problems, assign actions and monitor whether improvements were needed.
“These checks identified when remedial actions were required, who was responsible to rectify the concern and when this was to be completed by.” from the report
No registered manager
needs fixingThe home had been without a registered manager for more than 18 months and had several manager changes. Inspectors said the provider needed to ensure managers applied for registration when they took up their roles.
“The service had not had a registered manager in post for over 18 months.” from the report
Management changes
needs fixingThe report records three managers recruited during this period. A relative said managers were lovely but did not seem to stay, so families should ask about current stability.
“In this period the provider had recruited three managers.” from the report
Training and supervision
minorOne staff member's medicines training needed refreshing. Most staff had not had formal supervision since October 2016, although further supervision was planned.
“Most staff had last received formal supervision in October 2016.” from the report
- 01Is there now a registered manager, and when was their registration completed?
- 02How many managers have worked at the home since this inspection, and how long has the current manager been in post?
- 03Has all medicines training been refreshed, and how is staff competence checked?
- 04How often do staff now receive formal supervision?
- 05How are medicines and environmental risk checks monitored to ensure the improvements found in 2017 continue?
This was an announced inspection covering all five key questions, based on discussions, observations and checks of selected records. This explanation was written from the published report of 8 July 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 Honeysuckle Cottage
3 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- January 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2017Goodup from Requires improvementSafe: GoodResponsive: GoodWell-led: Requires improvement
- July 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2013
Report published without a new overall rating.
- September 2012
Registered with the Care Quality Commission on 11 September 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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