CQC report explained · a residential care home
What the CQC found at LIGHT AND HOPE
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 said they felt safe and medicines were given as prescribed. However, risk assessments and medicines records lacked enough detail or consistency, and the home had not registered with the local environmental health team.
- Effective?
- Requires improvement
- This question was not inspected during this visit. The previous rating was carried forward.
- Caring?
- Requires improvement
- This question was not inspected during this visit. The report says people received good-quality day-to-day care and staff relationships were caring and supportive.
- Responsive?
- Requires improvement
- People had choices and took part in some activities, but care planning did not consistently include longer-term goals, independence and meaningful activities. The home also had no links with an advocacy service.
- Well-led?
- Requires improvement
- The provider had introduced audits and checks, but these did not identify all the problems found by inspectors. Records were incomplete, some required training had not been obtained, and oversight remained ineffective.
What inspectors found, May 2023
Rated Requires Improvement; inspectors found kind day-to-day care, but person-centred planning and management checks were still not good enough.
This was an unannounced focused inspection on 13 and 22 March 2023. Inspectors checked whether the home had followed its action plan, focusing on Safe, Responsive and Well-led. They spoke with two people and two staff members, observed care, and reviewed care, medicines, recruitment and management records.
Some improvements had been made since the previous inspection, which was rated Inadequate. People told inspectors they felt safe and were happy with their care. Staff were safely recruited, medicines were given as prescribed, and staff supported people with kindness and good communication.
However, care plans did not always give enough detail about people's goals, choices and risks. The home did not always support people to develop independence or take part in activities they wanted. Management checks had not found important shortfalls, including incomplete records, inconsistent medicines recording and missing checks on food safety and fire marshal cover.
The overall rating changed from Inadequate to Requires Improvement. The home is no longer in Special Measures, but it still breached Regulations 9 and 17. Safe, Responsive and Well-led were rated Requires Improvement; Effective and Caring were not inspected in this visit and their previous ratings were carried forward.
People felt safe
People told inspectors they felt safe with the support they received. Staff knew how to report safeguarding concerns and had received safeguarding training.
“People said they felt safe with the support provided.” from the report
Kind daily care
People gave positive feedback about their care. Staff supported people's communication, choices and relationships, and treated their equality and diversity with respect.
“People provided positive feedback about the care they received.” from the report
Safe recruitment
The home completed employment history checks and DBS checks before staff started. People were involved in recruitment where possible.
“Staff were recruited safely.” from the report
Improvement since the last inspection
The home improved from Inadequate and was no longer in breach of Regulation 12. It also left Special Measures after demonstrating some improvement.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulation 12.” from the report
Care plans lacked detail
seriousPlans did not always explain how people's goals, risks and independence would be supported. This meant care was not consistently personalised or focused on longer-term aspirations.
“Support plans were not always kept up to date with the most recent information to support people with their care and support needs.” from the report
Limited support for independence
needs fixingPeople were not always helped to develop daily living skills or take positive risks. For example, one person wanted to cook but had not been given suitable equipment or a risk assessment to support this.
“People were not always being encouraged to develop their daily living skills, such as helping with the preparation of meals or snacks.” from the report
Management checks missed problems
seriousAudits did not identify all the issues found during the inspection. Care records were incomplete, incident patterns were not analysed, and the provider had not fully checked whether improvements were effective.
“The provider had developed a suite of various audits and checks to monitor the quality of care.” from the report
Medicines records were inconsistent
needs fixingPeople received their medicines as prescribed, but administration times were not always consistent and two medicines recording systems did not match.
“Although given with food as directed, the administration timings required to be consistent and this had not been picked up in the auditing of records.” from the report
Some safety arrangements were incomplete
seriousThe home had not registered with the local environmental health team. It also had only one trained fire marshal, although at least one was required on each shift.
“However, only one staff member in the team was a trained fire marshal, where the service is required to have a minimum of one on each shift.” from the report
- 01How have you updated each person's care plan to include longer-term goals, independence and positive risk-taking?
- 02What has changed to help people take part in activities they want, including cooking and activities outside the usual local venues?
- 03How do you now check that medicines are given at the correct times and that all medicines records match?
- 04Have you registered with the local environmental health team, and how many trained fire marshals are now available on each shift?
- 05What evidence can you show that your audits now identify and fix incomplete care records and recurring incident patterns?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 10 May 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, August 2022
Rated Inadequate and placed in special measures; inspectors found serious safety, care and leadership failures.
This was the first inspection of the newly registered home. It was unannounced. An inspector visited on 4 July 2022 and reviewed care plans, risk assessments, fire safety records, medicines records, training records and key policies. Feedback was also gathered from people, a relative, staff and outside professionals.
The main concerns were fire safety, medicines, infection control, risk assessments and staff competency. Fire doors were wedged open, some self-closing mechanisms were not working, and emergency plans did not properly cover nights when only one staff member was present. Medicines had not been stored or monitored safely, despite earlier advice from a pharmacy professional.
People received essential personal care, food, drinks and medicines, but inspectors found little conversation, activity or support to go out and follow interests. Care plans lacked important detail, people's wishes about future care had not been explored, and their privacy and dignity were not always respected.
The overall rating was Inadequate. Safe and well-led were rated Inadequate, while Effective, Caring and Responsive were rated Requires Improvement. The home was placed in special measures, meaning CQC will keep it under review and normally re-inspect within six months if registration is not being cancelled.
Safeguarding awareness
Staff and management showed knowledge of safeguarding and how concerns should be reported. A relative's concerns had also been shared with the local authority safeguarding team.
“Anything that you feel is not right you should whistleblow to someone of a higher position to report anything that you do not feel is right.” from the report
Access to health support
The management team contacted a range of health professionals to help meet people's needs, including medical, therapy, nutritional and mental health services.
“The management team told us about contact they had made with a range of health professionals in order to access support to meet an individual's needs.” from the report
Staff could seek support
Staff said they could approach the manager for advice and felt supported in their roles.
“I have a brilliant support system and supervision at Light and Hope that enables me to carry out my role effectively.” from the report
Action around nutrition
The provider tried to support a person who was often declining food and sought help from outside professionals.
“This showed the provider took appropriate action to try to support this person's nutritional needs.” from the report
Fire safety
seriousThe fire risk assessment had not been reviewed on time. Fire doors were propped open, some self-closing mechanisms were disconnected or faulty, and staff knowledge and alarm-testing records were not adequate.
“Fire doors were propped open, some door self closing mechanisms were disconnected or not working properly, staff knowledge required refreshing” from the report
Medicines systems
seriousMedicines were not always kept in their original boxes, the storage temperature was not recorded and cupboard keys were not kept safely. Some instructions for medicines given when needed were also not detailed enough.
“This placed people at risk of receiving the wrong or ineffective medicines.” from the report
Limited daily stimulation
needs fixingPeople spent long periods alone in bedrooms without enough activities, conversation or support to follow their interests or go out.
“There is no TV, nothing all day just [person] left in bed alone staring at plain walls.” from the report
Poor quality monitoring
seriousThe provider had not developed effective audits or feedback systems. As a result, important problems had not been identified or addressed.
“The provider had not developed quality assurance systems and processes.” from the report
Incomplete care planning
needs fixingCare plans did not always explain clearly how staff should provide safe care. Inspectors also found that people's future care wishes and personal preferences had not been properly explored.
“There was a lack of detail included in care plans which meant staff did not always have clear instructions to be able to provide safe and effective care.” from the report
- 01What has been done to fix the fire doors, self-closing mechanisms, alarm testing and night-time evacuation arrangements?
- 02How are medicines now stored, temperature-checked and recorded, and who is assessed as competent to administer them?
- 03What regular activities, outings and social contact will each person receive, and how will this be recorded?
- 04How have care plans been rewritten to give staff clear instructions about each person's risks, preferences and support needs?
- 05What audits and feedback meetings are now in place to identify and correct safety and care problems?
This was the first comprehensive inspection of the newly registered home and covered all five key questions, with a visit on 04 July 2022 and inspection activity continuing until 12 July 2022. This explanation was written from the published report of 12 August 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 LIGHT AND HOPE
2 rated inspections over a year: the service has improved, from Inadequate to Requires improvement.
- May 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2022InadequateSafe: InadequateResponsive: Requires improvementWell-led: Inadequate
- January 2021
Registered with the Care Quality Commission on 4 January 2021.
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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At least 100 live-in carers within about an hour of Hertfordshire
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 £980 to £1,300 a week. 82 can care for a couple. 12 years' experience on average.
“She handled the new situation in front of her with such professionalism and I felt I could trust her 100%.”
“She was v competent and confident and we felt our mum was safe in her care. She supported us through a difficult time.”
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.