CQC report explained · a residential care home
What the CQC found at 231 Stafford Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough trained staff, better risk assessments, suitable fire safety arrangements, improved infection control and safe medicines systems.
- Effective?
- Good
- Care records were complete and personalised. Staff received training and supervision, and people were supported with food, healthcare, independence and communication.
- Caring?
- Good
- No separate rating was given in this report.
- Responsive?
- Good
- No separate rating was given in this report.
- Well-led?
- Requires improvement
- Management arrangements and quality monitoring had improved, but there was no registered manager and the improvements needed to be embedded and sustained.
What inspectors found, February 2024
Rated Good overall; safe and effective care improved, but well-led was Requires Improvement and the home had only recently left Special Measures.
This was an unannounced follow-up inspection on 27 November 2023. Inspectors spoke with people, a relative, staff and health professionals. They reviewed care and staff records, medicines, finances, incidents and the home environment.
Inspectors found clear improvements since the previous inspection. There were enough trained staff, care records were up to date, risks were better managed, medicines were checked properly and the environment had been improved. People were supported with choice, independence, activities and healthcare.
The home was rated Good overall. Safe and Effective were rated Good. Well-led was rated Requires Improvement because there was no registered manager in post and the improved management systems still needed to become consistent and lasting. The home was no longer in breach of regulations or in Special Measures.
Staffing improved
All permanent care staff posts had been filled, with no agency staff rostered. Inspectors found enough trained and supervised staff to meet people's needs.
“At this inspection we found there were enough trained and supervised staff available to meet people's needs safely and effectively.” from the report
Safer care planning
People had up-to-date, personalised plans showing what they could do independently and what support they needed.
“People's support plans were personalised and noted what people could do for themselves and what they required support with.” from the report
Medicines managed safely
Staff were trained to give medicines, records were completed and medicines were stored securely. Managers and healthcare professionals audited medicines.
“Staff completed medicines administration records (MAR) appropriately to confirm people had receive the right medicines at the right times.” from the report
People involved in daily life
People helped plan their activities and took part in meetings about their care, food and activities.
“People contributed to their weekly activity plans. These plans listed people's care and support needs throughout the week.” from the report
No registered manager
needs fixingThere was no registered manager when inspectors visited. A relative said frequent changes in managers affected continuity.
“Managers are coming and going, which doesn't help the service There is no continuity.” from the report
Leadership needs to settle
needs fixingThe deputy manager was supported by managers from other services and the area manager. The report says the management improvements were not yet fully established.
“The service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.” from the report
Improvements must last
minorQuality checks had improved, but inspectors said they needed to be embedded and sustained over time.
“Quality assurance processes had improved to enable monitoring, and drive improvements at the service. These need to be embedded and sustained.” from the report
- 01Has a registered manager now been appointed, and how will you provide continuity while that appointment is completed?
- 02How do you check that the improved quality assurance systems continue to identify and fix problems?
- 03How are staffing levels maintained if permanent staff are absent or people's needs change?
- 04How do you make sure each person's swallowing, nutrition, fire safety and health guidance is followed every day?
- 05How are people and relatives involved in reviewing care plans, activities and environmental changes?
This was an unannounced follow-up inspection of action required after the previous inspection; where key questions were not inspected, previous ratings were used in calculating the overall rating. This explanation was written from the published report of 16 February 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, September 2023
Rated Inadequate and placed in special measures; inspectors found serious risks linked to care records, staffing, medicines and leadership.
This was an unannounced focused inspection. Inspectors visited on 15 and 18 November 2022, spoke with people, staff, managers, a relative and healthcare professionals, and checked care records, medicines, staffing, the building and quality checks.
The home was not able to show that people were receiving safe or effective care. Some people had no risk assessments or care plans. Other records were inaccurate or out of date. Staffing was too low, agency staff were not properly inducted, and some staff were working very long shifts.
Inspectors also found problems with medicines, infection control, fire safety, equipment and support for health needs. The home had no registered manager at the time, and its quality checks had failed to identify serious problems.
The overall rating changed from Good at the previous inspection to Inadequate. Safe, Effective and Well-led were all rated Inadequate. The inspection did not assess Caring or Responsive, so their previous ratings were used.
Respect for individual needs
The report says staff recognised people as individuals and were motivated to provide person-centred support, even though the provider's systems made this difficult.
“Staff recognised people as individuals with unique experiences, preferences and aspirations and were motivated to meet their needs in a person-centred way.” from the report
Least restrictive support
Inspectors found that staff supported people in the least restrictive way possible and acted in their best interests.
“Staff supported them in the least restrictive way possible and in their best interests” from the report
Some immediate financial safeguards
The acting manager introduced tighter controls after money went missing. These included a new safe, restricted access and daily checks.
“Measures introduced included strictly restricting access to people's money, the purchase of a new safe, daily checks of people's physical cash and a daily audit of transactions.” from the report
Accessible ground floor
The ground floor was wheelchair accessible and people could use shared areas and the garden.
“The service was wheelchair accessible on the ground floor.” from the report
Missing and inaccurate care records
seriousTwo people had no risk assessments, needs assessments or care plans. Other records contained incorrect information, leaving staff without reliable guidance.
“Two people did not have assessments or care plans.” from the report
Too few suitably prepared staff
seriousThere were three staff on shift when four were expected on both inspection days. Agency and redeployed staff were not given an induction, so they did not understand people's needs and risks.
“On both days of our inspection there were 3 staff on shift when there should have been 4.” from the report
Unsafe health and medicines support
seriousInspectors found that medicines were not properly audited and not all staff were trained to administer them. Some people were not consistently supported in line with specialist eating and drinking guidance.
“The provider failed to operate processes to ensure people's medicines were always managed safely.” from the report
Fire and infection risks
seriousFire alarms were not tested weekly and fire drills had not been carried out. Inspectors also found uncovered kitchen bins and no risk assessment for moving soiled laundry to another service.
“The service's fire alarm system was not tested weekly in line with the provider's fire policy and staff did not carry out fire drills” from the report
Broken bathing equipment
needs fixingThe specialist bath and ceiling hoist were not working. One person who could not use the shower could only receive bed baths.
“This meant that one person, who could not use the shower was unable to bath either and could only be supported with bed baths.” from the report
Leadership and staff support
seriousThe home had no registered manager or deputy manager. Staff had not received supervision or appraisal, and quality checks had failed to identify serious problems over many months.
“The provider's quality assurance failings had been systematic, significant and consistent over time.” from the report
- 01How many staff are now scheduled on each shift, and how do you make sure agency staff understand each person's needs and risks before working alone?
- 02Have every person's risk assessment, needs assessment and care plan been rewritten and checked for accuracy?
- 03What evidence can you show that medicines are now audited regularly and that every staff member administering medicines is trained and assessed as competent?
- 04Has the specialist bath and ceiling hoist been repaired, and what alternative personal care is available until then?
- 05What action has been taken to appoint a registered manager and provide staff with regular supervision and appraisal?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were used. This explanation was written from the published report of 7 September 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.
Every inspection of 231 Stafford Road
4 rated inspections over 9 years: the service has held its Good rating throughout.
- February 2024Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2023Inadequatedown from GoodSafe: InadequateEffective: InadequateWell-led: Inadequate
- August 2017Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- December 2014GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 22 November 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Sutton
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 £1,230 a week. 81 can care for a couple. 11 years' experience on average.
“She cared for my mum with Alzheimer's with endless patience and kindness, always arriving with a smile and a positive attitude”
“Terry has been of invaluable help to our family while working as a part-time live-in carer for our mother for approximately 6 months”
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.