CQC report explained · a residential care home
What the CQC found at Laburnum 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
- Some risk assessments lacked important detail, and staff were not always following agreed safety measures. Inspectors found potential risks involving wheelchair belts, diet and access to the home, although no harm was identified.
- Effective?
- Good
- People's needs and choices were assessed and care was delivered in line with guidance. Staff had relevant training and supported people with healthcare, nutrition and everyday choices.
- Caring?
- Good
- This key question was not inspected during this focused visit. The report describes respectful staff, privacy and people's involvement in choices, but does not give a current rating for Caring.
- Responsive?
- Good
- This key question was not inspected during this focused visit. The report does not give a current rating for Responsive.
- Well-led?
- Requires improvement
- The home had management and audit systems, but the audits did not always identify concerns found by inspectors. Inspectors said leadership and management were inconsistent, although the manager was open to improvement and staff and families were involved.
What inspectors found, August 2023
Rated Requires Improvement; inspectors found kind and effective care, but weaknesses in risk assessments and quality checks could put people at risk.
This was an unannounced focused inspection after concerns about incidents and staffing levels. One inspector visited on 28 June and 4 and 5 July 2023. They reviewed three care records, medicines, incidents, audits and recruitment records, observed care, and spoke with people, relatives, staff and professionals.
The home was rated Requires Improvement overall. Safe and Well-led were both Requires Improvement. Inspectors found gaps in some risk assessments, including risks linked to wheelchair safety, food choices and access to the front door. They also found that audits had not always identified these problems.
Effective was rated Good. People were supported by trained staff, involved in their care, helped to access healthcare and supported to make choices. Inspectors also found respectful care, privacy in people's own flats and opportunities for social activity.
This focused inspection did not assess Caring or Responsive. The report says the overall rating changed from Good at the previous inspection in 2018 because of the findings about safety and leadership.
Respectful, private care
Staff spoke respectfully and personal care was provided in people's own flats to protect privacy and dignity.
“Personal care was delivered in people's own flats, to ensure privacy and dignity.” from the report
Choice and independence
People could choose where to spend their time and were supported in the least restrictive way possible.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests” from the report
Trained staff and healthcare support
Staff had training suited to supporting people with learning disabilities and autism. People were helped to attend medical appointments and staff followed professional advice.
“All staff had completed an induction and had undergone a programme of training aligned to supporting people with learning disabilities and autism” from the report
Safe medicines and recruitment
Inspectors found medicines were stored and administered safely. Recruitment checks, including references and DBS checks, were completed before staff started.
“People were only administered their medicines from staff who were trained to do so and who had completed yearly competency checks.” from the report
Listening to families
Regular meetings gave people and families a chance to share their views, and inspectors found evidence that feedback was acted on.
“Regular meetings were held with people and family members to enable them to share their views about the service.” from the report
Risk assessments lacked detail
seriousSome risk assessments did not explain clearly enough how staff should keep people safe. One assessment about wheelchair belts had no accompanying guidance.
“People had risk assessments in place, however we found some areas where risks assessments were lacking detail which could affect people's safety.” from the report
Agreed food support was not followed
seriousFood charts showed that staff were not following one person's risk assessment about eating certain foods. Inspectors said this could put the person at risk of harm.
“When we viewed this person's food charts, it was evident staff were not following the risk assessment, potentially putting the person at risk of harm.” from the report
Front-door safety
seriousInspectors saw the front door open while a person who was not allowed to leave alone was unsupervised in the lounge. Another person's need to leave freely had not been balanced safely with the risks to others.
“This person had a Deprivation of Liberty Safeguard in place (DoLS) which prevented them from leaving the home unaccompanied, however, they could have easily left the premises unnoticed.” from the report
Quality checks missed problems
needs fixingThe home's audits did not always identify the concerns found during the inspection. The provider said it would review its governance systems.
“We identified, however, there was some improvement needed, due to the audits not always identifying some of the concerns we found during our inspection.” from the report
- 01What changes have you made to the risk assessments for wheelchair belts, food choices and access to the front door?
- 02How do you check that staff are following each person's risk assessment in practice, including food and mobility support?
- 03What safer arrangements are now in place for people who need to leave the home freely while protecting people who cannot leave unaccompanied?
- 04How have your audits and quality checks been changed so they identify problems before they affect people's safety?
- 05What is the current position on the expired DoLS authorisation mentioned in the report?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected, and the report says ratings for uninspected questions carried over from the previous inspection. This explanation was written from the published report of 16 August 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, April 2019
Rated Good overall; inspectors found kind, effective care, but the home was Requires Improvement for leadership and oversight.
Inspectors visited on 25 and 26 March 2019. The first day was unannounced. They reviewed care records, medicines, incidents, staff checks and training, and quality audits. They observed care and spoke with people, a relative, staff and managers.
People were described as safe and happy. Staff were kind and respectful, and supported people to build skills, take part in the community and become more independent. Inspectors found good arrangements for medicines, staffing, food, healthcare and consent.
The main weaknesses were in leadership and oversight. The home had not told CQC about five authorised applications to restrict people's liberty. Care planning and learning after incidents, particularly where high-level physical restraint was used, also needed to improve.
The overall rating stayed Good, as did Safe, Effective, Caring and Responsive. Well-led fell from Good at the previous inspection to Requires Improvement.
Kind and respectful care
People said staff treated them well. Inspectors observed calm, compassionate relationships and staff supporting people patiently when they were upset.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Building independence
The home helped people gain skills, try new activities and move towards more independent accommodation.
“The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice, independence and inclusion.” from the report
Safe medicines and staffing
People said they received medicines on time. Records matched stock levels, and people and staff felt there were enough staff to meet people's needs.
“The management of people's medicines was safe and effective. We checked the stock levels of different people's medicines and found they matched records.” from the report
Involving people
People helped plan their care, meals and activities. The home used meetings, surveys and other feedback to involve people in how it was run.
“People and staff were actively involved in the design and delivery of the service through regular meetings.” from the report
Important notifications were missed
needs fixingCQC had not been told about five authorised applications to deprive people of their liberty. The notifications were sent the day after the inspection.
“CQC had not been notified of authorised applications for five people to deprive them of their liberty.” from the report
Restraint plans needed more detail
needs fixingInspectors found that care plans did not give clear enough, person-specific guidance for incidents involving high-level physical restraint. The home also needed clearer plans to reduce restraint.
“In light of the variety and high-level of physical restraint used within the service, detail in care plans needed to be improved to guide all readers consistently.” from the report
Learning after incidents needed strengthening
needs fixingDebriefs took place, but inspectors wanted a clearer focus on whether incidents and physical restraint could have been prevented, and whether responses were proportionate.
“We considered however there needed to be a clearer focus in these sessions on whether events, including the use of physical restraint, could have been prevented.” from the report
Some staff training was incomplete
minorStaff said more training about the conditions of the people they supported would be useful. The report says completion of this supplementary training needed to improve.
“The provider had supplementary training in place regarding this, but staff completion of this needed to be improved.” from the report
- 01What has changed to make sure all authorised liberty restriction applications are reported to CQC on time?
- 02Can we see an example of the current person-specific plan for behaviour and physical restraint?
- 03How do you work to reduce the use of high-level physical restraint for each person?
- 04How are people monitored and supported after physical restraint, and who reviews whether it could have been prevented?
- 05Has all supplementary training about the conditions of the people supported now been completed by staff?
This was a planned inspection of all five key questions, covering the premises and care provided; Safe, Effective, Caring and Responsive remained Good, while Well-led was rated Requires Improvement. This explanation was written from the published report of 4 April 2019 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 Laburnum Cottage
4 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- August 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Requires improvement
- September 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- May 2015
Registered with the Care Quality Commission on 19 May 2015.
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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