CQC report explained · a residential care home
What the CQC found at Joybrook
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- People received their medicines as prescribed, risk assessments had improved, and inspectors found enough staff to meet people's needs. Infection prevention arrangements were also judged effective.
- Effective?
- Good
- This question was not inspected during this visit. Its rating carried over from the previous inspection.
- Caring?
- Good
- This question was not inspected during this visit. Its rating carried over from the previous inspection.
- Responsive?
- Good
- This question was not inspected during this visit. Its rating carried over from the previous inspection.
- Well-led?
- Requires improvement
- Quality checks did not identify or fix some problems quickly enough. Medicines records and incident records were incomplete, and more work was needed to make the environment dementia friendly.
What inspectors found, March 2023
Rated Requires Improvement; inspectors found people were safe, but medicines records and quality checks were not reliable enough.
This was an unannounced focused inspection on 6 February 2023. Inspectors checked whether the home had followed its previous improvement plan, looking mainly at Safe and Well-led. They spoke with one person, six care staff and the deputy manager, reviewed care, medicines and staff records, and received feedback from three relatives.
The Safe rating improved from Requires Improvement to Good. Inspectors found enough staff, appropriate recruitment checks, safer medicines administration, improved risk assessments and effective infection control. People were protected from abuse, and incidents were investigated so lessons could be learned.
The Well-led rating remained Requires Improvement. The home had not identified or fixed some problems quickly enough. Medicines records were inaccurate or incomplete, some incidents had not been recorded, and the environment still needed improvement to help people with dementia find their way around. The overall rating remained Requires Improvement.
Improved medicines safety
Inspectors found that people received their medicines as prescribed and that the previous breach about safe medicines administration had been resolved.
“At this inspection we found enough improvements had been made and the service was no longer in breach of regulation 12.” from the report
Enough staff and safer recruitment
Inspectors found enough staff to meet people's needs. Recruitment files included identity checks, references and DBS checks.
“People continued to receive support from staff that had undergone robust checks prior to commencing the role.” from the report
Protection from abuse
Staff understood how to recognise and report abuse. People told inspectors they felt safe, and the home worked with safeguarding agencies.
“People were safeguarded from risk of abuse.” from the report
Improved risk assessments
Risk assessments covered relevant areas such as mobility, diet, daily habits and behaviour. Behaviour monitoring records had also improved.
“Risk assessments had improved, and people had these in place for areas of need that were relevant to their individual presentation.” from the report
Support from other services
The home worked with district nurses, mental health teams and the local authority when people needed additional health care.
“The provider worked in partnership with other agencies to meet people's healthcare needs.” from the report
Medicines records were not reliable
seriousStaff recorded medicines inaccurately for two weeks. Some medicines were not signed for, and PRN pain relief outcomes were not recorded as required. Inspectors could not be assured that medicines records were accurately checked.
“We could not be assured that medicines administration was accurately recorded and audited.” from the report
Some incidents were not recorded
needs fixingIncident and accident records were not easy to access on the inspection day, and the provider had failed to record all incidents.
“During the inspection we identified the provider had failed to record all incidents.” from the report
The home was not fully dementia friendly
needs fixingMore work was needed to help people with dementia orientate themselves around the home. This had also been raised at the previous inspection.
“Improvements were still needed to the environment to ensure it was dementia friendly.” from the report
Quality checks did not act quickly enough
seriousThe home's governance systems had not been improved enough to identify and remedy problems promptly. This led to a continued breach of Regulation 17.
“Issues identified at this inspection had not always been remedied by the provider in a timely manner.” from the report
- 01What checks are now being used to make sure every medicine is signed for and PRN medicines are recorded correctly?
- 02How do managers identify and act on missing or inaccurate medicines records?
- 03How are all accidents and incidents recorded and made available for review?
- 04What changes have been made to help people with dementia find their way around the home?
- 05What actions are included in the improvement plan for the Regulation 17 breach, and when will they be completed?
This was a focused inspection of Safe and Well-led only; the other key question ratings carried over from the previous inspection. This explanation was written from the published report of 4 March 2023 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, March 2022
Rated Requires Improvement; inspectors found kind and responsive care, but safety and management systems were not reliable enough.
Inspectors visited on 31 January and 4 February 2022 after intelligence about a recent COVID-19 outbreak. They checked infection control, vaccination requirements, care records, medicines, staffing, complaints, audits and how people experienced the home. They spoke with people, staff, a relative, a visiting healthcare professional and the deputy manager.
The home was not always safe. Risk assessments were missing or incomplete, medicines records did not always explain why as-needed medicines were given, and staff did not always use masks correctly. Staffing shortfalls meant people were sometimes left without meaningful interaction. The home also needed to improve some infection control arrangements.
Inspectors found good care in several areas. People were treated with kindness and dignity, had choices about food and care, received healthcare support, and could share their views. The home supported people with communication, end-of-life wishes and activities, although activities and personalised care were not always consistent.
The overall rating changed from Good at the previous inspection in August 2018 to Requires Improvement. The safe and well-led ratings also changed to Requires Improvement. The provider took prompt action after the inspection, but inspectors required an action plan and said they would continue to monitor progress.
Kind and respectful staff
People and relatives spoke positively about staff. Inspectors found that people were treated with dignity and respect.
“People and relatives were positive about staff and management, telling us they were caring and supported them well.” from the report
Food and healthcare
People could choose from a varied menu and received support with dietary needs. The home arranged healthcare appointments and worked with other professionals.
“People were supported to access food and drink that met their dietary needs and preferences.” from the report
Safeguarding awareness
Staff understood how to recognise and report abuse, and records showed safeguarding training had been completed.
“Staff were aware of how to identify, report and escalate any concerns of suspected abuse.” from the report
Involvement in care
People were asked for their views through meetings and relatives were involved in care plan reviews and decisions.
“People were encouraged to share their views through regular 'resident meetings'.” from the report
Missing risk guidance
seriousA person's care plan had no risk assessments despite known behaviours that could challenge others. Staff did not appear confident about safely de-escalating an incident.
“People were not always protected against the risk of harm as the provider had failed to ensure risk assessments were always in place to guide staff when faced with identified risks.” from the report
Incomplete medicines records
seriousRecords for as-needed medicines did not explain why they were given or whether they had helped. The provider sent protocols after the inspection.
“Medicine Administration Records (MARs) did not contain the reason for PRN (as and when required) medicines being administered, nor whether they had an impact on the person's ailment.” from the report
Infection control
seriousSome staff did not wear masks correctly or put them on before entering. Some hand-sanitiser stations were blocked.
“On the second day of inspection we saw that some staff did not put masks on until they had already entered the home.” from the report
Staffing and social contact
seriousThere were staffing shortfalls and staff often had to cover care, cooking and housekeeping. People were sometimes left in communal areas without interaction or activities.
“This meant there were insufficient staff available to people in the main lounge.” from the report
Weak management checks
seriousThe home's checks had not identified or dealt with several problems before the inspection. Inspectors found a breach of good governance.
“The provider did not always operate their governance systems effectively.” from the report
Environment and signage
needs fixingThe lift was out of use, some flooring was cracked or uneven, and room signs were missing. Inspectors recommended specialist advice on dementia-friendly signage.
“The provider failed to display signs indicating the purpose or occupancy of each room, leading to confusion for one person who told us they were not quite sure where their bedroom and communal bathroom were.” from the report
- 01What evidence can you show that every person now has an up-to-date risk assessment, including guidance about behaviours that may challenge others?
- 02How do you check that staffing levels are sufficient throughout each day, especially when staff are also cooking or doing housekeeping?
- 03How are as-needed medicines recorded now, including the reason they were given and whether they worked?
- 04What checks ensure staff wear masks correctly and that hand-sanitiser stations remain accessible?
- 05What activities are now available for people who stay at the home, and how are these matched to each person's interests and needs?
This began as a focused infection-control inspection after a COVID-19 outbreak, but concerns found on the first day led to a comprehensive inspection across all five key questions. This explanation was written from the published report of 17 March 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.
Every inspection of Joybrook
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- June 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 13 December 2010.
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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