CQC report explained · a residential care home
What the CQC found at 2 Laurel Drive
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were supported safely, with enough staff on shift and care plans covering risks such as eating, drinking, moving and continence care. Some staff had not taken part in fire drills, and some risk assessments were generic.
- Effective?
- Good
- This area was not reviewed in this focused inspection.
- Caring?
- Good
- This area was not reviewed in this focused inspection.
- Responsive?
- Good
- This area was not reviewed in this focused inspection.
- Well-led?
- Good
- The new manager had identified areas for improvement and staff spoke positively about the manager. However, serious incidents had not always been reported to CQC promptly, and relatives had not always felt involved in care.
What inspectors found, May 2021
Individual Care Services - 2 Laurel Drive is rated Good; inspectors found safe care and improved infection controls, but some records and staff arrangements needed attention.
This was a focused inspection on 13 May 2021. Inspectors visited the home, observed care, spoke with staff and relatives, and checked care plans, risk records, medicines records, policies and audits. They reviewed the Safe and Well-led areas only.
The home was rated Good for Safe and Good for Well-led. People were supported safely, there were enough staff on shift, medicines were given as prescribed, and the home was clean. Infection control problems identified before the visit were addressed immediately, and inspectors found COVID-19 risks were then managed consistently.
There were still some areas to improve. Not all staff had taken part in fire drills, some risk assessments were too general, agency staffing could affect consistency, and medicine storage temperatures were not always recorded. The provider had also not always reported serious incidents to CQC promptly.
The overall rating remained Good, as it had been at the previous inspection. Safe improved from Requires Improvement to Good. The report says the new manager had identified improvements to work on, but there was not yet a registered manager in place.
Safe support
People were supported safely and on time. Staff understood people's risks and followed care plans when supporting movement and transfers.
“People were supported safely and in a timely way.” from the report
COVID-19 controls
The provider acted quickly after concerns were raised about infection control and agency staff checks. Inspectors found the home was then following government guidance consistently.
“Risks related to Covid-19 were now consistently well managed.” from the report
Medicines
Medicines records showed that people received their medicines as prescribed. Staff had guidance for giving medicines when needed.
“Medicine administration records (MARs) had been completed accurately to show people had received their medicines as prescribed.” from the report
Improved safety
Fire safety arrangements had improved since the previous inspection and the improvement had been maintained.
“At this inspection, we found improvements had been made and sustained.” from the report
Fire drills
needs fixingNot all staff had taken part in a fire drill. The head of service said this would be dealt with immediately.
“However, not all staff had taken part in a fire drill.” from the report
General risk assessments
needs fixingSome risk assessments were not tailored enough to each person. The manager had recognised this and planned to make them more person-centred.
“Some risk assessments were generic, but the manager had already identified this as an area for improvement.” from the report
Agency staffing
needs fixingVacancies meant some shifts were covered by agency staff. Staff said this could reduce consistency of care, especially when a shift was mainly agency-covered.
“Staff felt it did not give people consistency of care, for example, when a shift was predominantly covered by agency staff.” from the report
Medicine storage records
needs fixingStaff did not always record the temperature of the medicine cupboard or fridge. The manager said this would be addressed and checked.
“Staff did not always record the temperature of the medicine cupboard or medication fridge.” from the report
Incident reporting
needs fixingThe provider did not have a reliable system for reporting serious incidents promptly to CQC and other relevant agencies. A new system was being introduced.
“Incidents had not always been reported to us in a timely way.” from the report
Relative involvement
minorSome relatives did not feel consistently involved or listened to. The manager said COVID-19 restrictions and management changes had affected this, and planned more meetings.
“Relatives told us they felt the new home manager had not consistently involved, or listened, to them in the care and support of their relation.” from the report
- 01Have all staff now completed fire drills, and how often are drills carried out?
- 02Have risk assessments been rewritten so they reflect each person's individual needs?
- 03How many shifts are currently covered by agency staff, and how do you maintain consistency for residents?
- 04Are medicine cupboard and fridge temperatures now recorded every time they should be?
- 05How are relatives now involved in care reviews and decisions about their family member?
This was a focused inspection of Safe and Well-led only; the other three key question ratings were not reviewed in this visit. This explanation was written from the published report of 26 May 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, December 2018
Individual Care Services - 2 Laurel Drive was rated Good overall, but inspectors found fire safety needed improvement.
This was an unannounced, comprehensive inspection on 12 November 2018. One adult social care inspector and a dental inspector visited. They observed care, spoke with staff and relatives, and checked care plans, medicines, recruitment files and management records.
The home provided caring, effective and responsive support. Staff understood people's communication, supported their choices and helped them access health care and activities. Relatives said staff were kind and approachable.
The main shortfall was fire safety. Some fire doors were propped open or did not fully close, and specialist evacuation equipment had not been considered. The overall rating stayed Good, but Safe was rated Requires Improvement.
Kind and respectful staff
Staff responded calmly when people became anxious and treated them with dignity. Relatives described the staff as kind.
“People smiled when approached by staff who interacted with them in a positive, caring way.” from the report
Good understanding of communication
Staff understood people's gestures, sounds and other non-verbal communication. This helped people express choices and showed when something was upsetting them.
“People had very limited verbal communication and used gestures and non-verbal communication which staff understood well.” from the report
Personalised activities and choices
People were supported with activities they enjoyed, including outings, holidays and local events. Staff also supported everyday choices such as clothing and perfume.
“Staff planned activities based on what people liked to do.” from the report
Suitable staffing and training
Inspectors found enough staff with suitable skills and experience. Staff received induction, training and supervision.
“There were enough staff on shift with the appropriate level of skills, experience and support to meet people's needs and provide effective care.” from the report
Fire doors and evacuation
seriousSome fire doors were propped open and some did not fully close. The home had not considered specialist equipment such as evacuation mats, creating a potential safety risk.
“Propping open fire doors with plastic wedges posed potential risks to people” from the report
Medicine storage
needs fixingThe medicine fridge and the room where medicines were kept were not lockable at the inspection. The home said replacement equipment and a new door would be provided.
“The medicine fridge was not lockable, nor was the allocated room locked.” from the report
Fluid records
needs fixingStaff recorded drinks but did not total the amounts. This meant it was not always possible to monitor accurately whether people had reached their fluid targets.
“However, staff had not totalled amounts of fluid drunk by people which meant accurate monitoring was not consistent.” from the report
Accessible information
minorCare plans were being moved to a new format, but accessible pictorial versions were not yet available. The home said these would be completed before the end of 2018.
“Easy read pictorial care plan versions had no yet been completed for people” from the report
- 01Can you show us that all fire doors now close properly and explain how staff prevent them being propped open?
- 02Are the medicine fridge and medicine room now lockable, and how are medicine storage checks recorded?
- 03How do you now total and review each person's daily fluid intake?
- 04Have accessible pictorial care plans and complaint information been completed for each person?
- 05How do you record the manager's oversight of delegated audits and make sure actions are completed?
This was a comprehensive inspection covering all five key questions, with an additional detailed review of oral health support. This explanation was written from the published report of 7 December 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 2 Laurel Drive
3 rated inspections over 5 years: the service has held its Good rating throughout.
- May 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2018Goodstayed GoodSafe: Requires improvementWell-led: Good
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 February 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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