CQC report explained · a residential care home
What the CQC found at Innisfree Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks, medicines, staffing, infection control and the home environment were generally managed safely. Some incidents and safeguarding concerns had not always been identified for reporting.
- Effective?
- Good
- People's choices and legal rights were respected, and staff were trained and supported. One healthcare referral had been overlooked when care plans were reviewed.
- Caring?
- Good
- Staff were described as kind, caring and respectful. Inspectors saw people being supported to make choices and keep their independence.
- Responsive?
- Good
- Care plans included people's backgrounds, interests and preferences, and complaints were dealt with effectively. Activities had improved, but some people wanted more options.
- Well-led?
- Requires improvement
- Management systems had improved and previous breaches had been addressed. However, reporting systems had not always identified concerns that needed to be reported to CQC or the local authority.
What inspectors found, June 2022
Rated Good overall, but inspectors found the home was not always well-led and needed to improve its reporting systems.
This was an unannounced follow-up inspection on 12 and 19 May 2022. Inspectors spoke with people living in the home, relatives, staff and health and social care professionals. They reviewed care records, medicines records, staff recruitment files and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found kind staff, safer medicines systems, improved staffing and care plans that reflected people's needs and preferences. The home was clean and well maintained.
The home was rated Requires Improvement for Well-led. Some safeguarding concerns and incidents had not always been reported to CQC or the local authority as required. Inspectors also found some gaps in recruitment records and one missed healthcare referral.
The overall rating improved from Requires Improvement at the previous inspection, when five regulations had been breached. At this inspection, the provider was no longer in breach of those regulations.
Kind and respectful care
People said staff were kind, knew them well and respected their choices, privacy and independence.
“People were supported by staff who were kind, caring and respected their choices.” from the report
Safer medicines
Medicines were stored, checked and given safely. Records included people's preferences and guidance for medicines given when needed.
“Medicines were managed safely. Protocols for as required medicines gave clear guidance when they may be needed” from the report
Improved staffing
Staffing levels had improved and the home had reduced its reliance on agency staff. A more consistent team knew people better.
“Staffing had improved to ensure people received support from a consistent team who knew them well.” from the report
Personalised care
Care plans included people's histories, interests, wishes and support needs. Staff involved people and families in care decisions.
“Improvements had been made to ensure care plans were person centred and contained consistent information about people's preferences and wishes.” from the report
Complaints handled
Complaints were recorded, investigated and acted on. People said they felt able to raise concerns.
“Complaints and concerns were managed effectively. Complaints were recorded, investigated and actions taken to resolve them.” from the report
Reporting concerns
needs fixingSome safeguarding concerns and incidents had not been reported to CQC or the local authority when required. The manager changed the systems after the inspection and submitted the missing notifications retrospectively.
“Whilst the service had reported and managed safeguarding concerns, these had not always been reported to CQC or the local authority as required.” from the report
Recruitment records
needs fixingTwo staff files did not contain interview records, and gaps in employment had not always been explained. The recruitment audits had not found these omissions.
“Two staff members did not have an interview record. When people had gaps in employment the provider had not always ensured these were accounted for.” from the report
Activities and follow-up
minorActivities had improved, but some people said there was not enough to do. Inspectors also found that one further healthcare referral had been overlooked.
“However, some people said they would appreciate more options. One person said, "There isn't really enough to do.” from the report
- 01What changes were made to the incident and safeguarding systems after the inspection, and how are you checking that all required reports are now made?
- 02How do you make sure recruitment files contain interview records and explanations for gaps in employment?
- 03How will you make sure healthcare referrals and follow-up actions are not missed when care plans are reviewed?
- 04What activities are currently available, and how do you offer enough choice for people who want more to do?
- 05How are people's food preferences and requests for better options being acted on?
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 23 June 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, April 2021
Innisfree Residential Home was inspected but not rated; inspectors found strong COVID-19 infection-control arrangements.
This was an announced, targeted inspection on 22 March 2021. It looked at how the home was preventing and controlling infection during the COVID-19 pandemic.
Inspectors were assured that the home had suitable arrangements for visitors, testing, PPE, social distancing, hygiene, admissions and managing possible outbreaks. Staff understood the procedures and supplies of PPE were plentiful.
The home continued activities and helped people keep in touch with relatives through window visits, video calls and telephone calls. The service was inspected but not rated, so this report does not give an overall quality rating.
Entry checks
The home had checks for staff and visitors entering, including temperature checks, declarations and suitable PPE.
“Clear procedures were in place for staff and visitors on entry to the service to minimise the risks of COVID-19 transmission.” from the report
Visiting arrangements
The visiting policy was kept up to date. Visitors had to take a lateral flow test, and a separate ventilated visiting area supported social distancing.
“A visiting policy outlined current systems, this was updated regularly.” from the report
PPE and staff training
The home had plentiful PPE and staff had been trained in hand hygiene, infection prevention and how to put on and remove PPE.
“There were plentiful supplies of (PPE). Staff had been trained on hand hygiene, infection prevention control and donning and doffing.” from the report
Safe admissions
Rooms with a separate entrance were available so new people could complete the required isolation period.
“Rooms were available with a separate entrance to the home to enable the required isolation period to be completed.” from the report
Keeping in touch
Activities continued, and people were supported to maintain relationships through window visits, video calls and telephone calls.
“Activities had continued. People had been supported to maintain relationships through window visits, video and telephone calls.” from the report
Inspectors raised no specific concerns in this report.
- 01What are the current arrangements for relatives visiting, and are visitors still required to complete any testing?
- 02How would you manage a COVID-19 outbreak now, and when was the contingency plan last reviewed?
- 03How would a new resident complete any required isolation period, and which rooms would be used?
- 04How are activities and contact with relatives being supported now?
- 05What were the home's ratings in areas that this targeted inspection did not cover?
This was a targeted inspection of infection prevention and control under the Safe question; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 7 April 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.
Every inspection of Innisfree Residential Home
3 rated inspections over 5 years: the service has held its Good rating throughout.
- June 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Inspected but not rated
- April 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2017GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: OutstandingWell-led: Good
- October 2014
Report published without a new overall rating.
- September 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 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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23 live-in carers within about an hour of North Somerset
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 £1,050 to £1,320 a week. 19 can care for a couple. 12 years' experience on average.
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.