CQC report explained · a residential care home
What the CQC found at 77 Russell Street
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 at increased risk because fire safety checks and precautions were not up to date. Cleaning arrangements and some medicines records were also incomplete.
- Effective?
- Good
- Care was based on people's needs, choices and goals. Staff had relevant training, and people were supported with food, healthcare and decision-making.
- Caring?
- Good
- Inspectors observed respectful and compassionate support. Relatives said staff understood people well and respected their choices, privacy and dignity.
- Responsive?
- Good
- Care plans were personalised and included communication needs, preferences and activities. People were supported to maintain relationships and take part in interests they enjoyed.
- Well-led?
- Requires improvement
- Management systems and audits did not reliably identify or address risks. Records were not always accessible when the registered manager was absent.
What inspectors found, January 2024
Jigsaw Creative Care Limited - 77 Russell Street was rated Requires Improvement; inspectors found kind, personalised care but serious fire safety and management weaknesses.
This was an unannounced inspection on 20 and 22 October 2023. One inspector observed care, spoke with relatives and staff, and checked care plans, medicines records, recruitment files and management records.
The home was rated Good for Effective, Caring and Responsive. People were treated with dignity, supported to make choices, and helped to enjoy activities and community life. Care plans were individualised and staff knew people's needs well.
The home was rated Requires Improvement for Safe and Well-led. Inspectors found fire risks, gaps in cleaning arrangements, incomplete medicines records and audits that had not identified important problems. They found breaches of Regulation 12 and Regulation 17.
Some immediate actions were taken after concerns were raised. These included arranging fire safety checks, servicing fire extinguishers, covering radiators, improving cleaning records, recording medicine-room temperatures and refurbishing the garden. CQC requested an action plan and said it would monitor progress.
Kind and respectful support
People were treated with dignity and compassion. Staff supported privacy, independence and personal choices.
“Relatives told us and we observed, staff respected people and treated them with dignity and compassion.” from the report
Personalised care
Care plans reflected people's needs, preferences, routines, communication and goals. Staff knew the people they supported well.
“Care plans were individualised and reflected people's current needs, preferences, and daily routines.” from the report
Activities and community life
People were supported to take part in activities suited to their interests and to socialise with others. Their wishes were respected if they did not want to join in.
“Examples included going to the cinema, attending discos, going to the park, and cycling.” from the report
Positive communication
Relatives were kept informed, and staff understood how people communicated. The management team was described as open during the inspection.
“Relatives we spoke with described a positive and close working relationship with the management team.” from the report
Fire safety
seriousFire risk assessments had not been reviewed since 2019, extinguisher servicing was overdue and a fire door was propped open. Inspectors said this placed people at increased risk of harm.
“Risks relating to fire safety had not been adequately assessed and mitigated placing people at increased risk of harm.” from the report
Weak management checks
seriousAudits had not identified problems with fire safety, infection control, radiators or medicines. This led to a breach of good governance requirements.
“Audits had failed to ensure fire safety arrangements were robust, placing people at increased risk of harm.” from the report
Cleaning and infection control
seriousThere was no cleaning schedule for much of the property or for bedrooms between respite stays. Inspectors also found dust, dirt and a bathroom without hand soap.
“There was no cleaning schedule for the rest of the property and for cleaning of rooms between respite stays.” from the report
Medicines records
needs fixingSome medicines records did not show allergy information or clear start and end dates. Medicine-room temperatures were not being recorded at the time of inspection.
“2 people's medicine administration records had blank start and end dates.” from the report
Recruitment evidence
needs fixingOne of four staff files checked did not contain a reference from a previous role involving children or vulnerable adults. The provider was advised to strengthen recruitment checks.
“We recommend the provider ensure satisfactory evidence of conduct and verification for leaving previous roles working with children and vulnerable adults are reviewed during the recruitment process.” from the report
- 01What has been done to update the fire risk assessment and keep fire extinguishers and fire doors safe?
- 02How do you now check that bedrooms are cleaned between respite stays and that all areas of the home are cleaned regularly?
- 03How are medicine records checked for allergies, start and end dates, and correct storage temperatures?
- 04How will management audits identify and correct safety problems before they put people at risk?
- 05What system is now in place so staff can access care and training records when the registered manager is absent?
This began as a focused inspection of Safe and Well-led, but concerns about premises and care-file records led CQC to widen it to Effective, Caring and Responsive; the previous rating was Good in all areas. This explanation was written from the published report of 10 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, October 2017
Rated Good; inspectors found safe and caring respite care, but Mental Capacity Act decisions were not recorded correctly.
This was an unannounced inspection of the respite care home. It can support up to three people at a time. One person was using the home during the visit.
The overall rating was Good, with Good ratings for Safe, Effective, Caring, Responsive and Well-led. The home had improved since the previous inspection, when Safe was rated Requires Improvement. Inspectors found better maintenance, stronger staff recruitment checks and suitable risk assessments.
Inspectors found kind and patient staff, individual care plans, suitable activities and good communication with families. Staff had the training and support they needed, and medicines were managed safely.
Inspectors found that decisions made in people's best interests were not recorded in line with the Mental Capacity Act. They recommended that the provider seek current guidance on recording these decisions. Inspectors could not speak directly to people using the home, so they relied on observations, records, staff and relatives' feedback.
Improved safety
The home had addressed earlier concerns about the property, garden and recruitment. Inspectors also found suitable staffing and risk management.
“Improvements had been made to maintain the property and garden to a good standard and reduce risks to people's safety.” from the report
Kind and respectful care
Staff were described and observed as kind and patient. People were supported to keep their dignity and independence.
“People were provided with privacy and dignity when they visited the service.” from the report
Individual support
Care was planned around each person's communication, preferences, routines, interests and changing needs. Staff were matched to people carefully.
“Staff knew people very well and care plans were focused on each individual, their preferences, routines and choices.” from the report
Activities and communication
People had access to activities suited to their interests, and relatives said communication with staff was good.
“People had a full and varied timetable of activities during the time they visited the service.” from the report
Mental Capacity Act records
needs fixingInspectors found that best-interest meetings and decisions were not recorded in line with the Mental Capacity Act. They made a recommendation for the provider to seek current guidance.
“However, we noted these were not recorded in accordance with the MCA.” from the report
- 01How are best-interest meetings and decisions now recorded in line with the Mental Capacity Act?
- 02How will you assess and update my relative's risks before their first respite visit?
- 03How will you make sure my relative receives their medicines at the right time during their stay?
- 04How will you match staff to my relative's communication needs, interests and routines?
- 05How will you keep our family informed about changes in my relative's needs during respite care?
This was an inspection of all five quality areas, but inspectors could not speak directly to people using the home and received feedback from three relatives. This explanation was written from the published report of 31 October 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 77 Russell Street
3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- January 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 13 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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