CQC report explained · a residential care home
What the CQC found at London Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People's risks were assessed and support plans gave staff detailed instructions. Inspectors also found safe staffing levels, safe medicine storage and appropriate safeguarding procedures, although medicines-counting improvements were still being completed.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Leadership, oversight and quality checks had improved. The provider was monitoring its action plan, carrying out quarterly audits and giving the registered manager more specialist support.
What inspectors found, January 2023
London Road rated Good; inspectors found safer, more person-centred care, but medicines counts and one infection-control practice still needed attention.
This was an unannounced, focused inspection on 5, 7 and 12 December 2022. One inspector and an Expert by Experience spoke with people, relatives, staff and professionals, observed care and checked records.
Inspectors found that risks were assessed and support plans explained how staff should keep people safe. Staffing levels were met, medicines were stored safely, and improvements had been made after earlier safety incidents. The home also worked more closely with health and social care professionals.
The service was rated Good overall, with Safe and Well-led also rated Good. This was not a full inspection of all five areas. The other ratings were carried forward from the previous inspection, when the service was rated Requires Improvement.
Clear risk planning
People's risks were assessed and staff had detailed instructions about how to keep them safe. Plans were reviewed when people's needs changed.
“Risks to people were assessed and actions for staff, to keep people safe, were detailed in related support plans.” from the report
Improved leadership
The provider had strengthened oversight and introduced regular quality reviews. Inspectors found this was having a positive effect on safety and the service's culture.
“The provider monitored progress on the service's action plans and had carried out quarterly audits to monitor the quality and safety of the service.” from the report
Focus on independence
Support plans were person-centred and staff were working to improve people's independence and quality of life.
“The service culture had improved with greater focus on promoting people's independence and improving their quality of life.” from the report
People and relatives were heard
People's views were collected through weekly meetings and used to plan menus and activities. Relatives' feedback had led to action.
“People's views were sought at a weekly house meeting which informed menu and activity planning for the following week.” from the report
Medicines counts
needs fixingRecords showed medicines had been given as prescribed, but the provider had identified that medicine counts needed to improve. Inspectors had not yet tested whether the planned action worked.
“The provider had identified improvement was needed in completing medicines counts and this work was underway to ensure people's medicine was always available and any errors could be identified promptly.” from the report
Infection-control practice
minorInspectors were only somewhat assured that protective equipment was being used effectively and safely. The practice of staff eating alongside people was not in line with national guidance at the time.
“The provider's process allowing staff to eat alongside people who use the service was not in-line with national guidance at the time of the inspection.” from the report
- 01Have the medicines-counting improvements been completed, and how do you now identify missing medicines or counting errors?
- 02What has changed about staff eating alongside people since the inspection?
- 03How will you make sure staffing remains at or above the home's safe staffing levels, particularly for senior staff and the deputy manager role?
- 04How are weekly house meetings and relatives' feedback used to plan activities and support people to go out more?
- 05How often are risk assessments and support plans reviewed when someone's needs change?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection. This explanation was written from the published report of 18 January 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, May 2022
London Road rated Requires Improvement; inspectors found risks were not always managed safely and oversight was not effective.
This was an unannounced focused inspection. Inspectors looked at Safe and Well-led because concerns had been raised about money, neglect, staff culture and cleanliness. They spoke with people, relatives, staff and professionals, and checked care, medicine, staff and management records.
People generally spoke positively about the home. They said they felt safe and respected, had enough to eat and drink, and described staff as kind and respectful. However, risk assessments were missing or out of date, staff competency checks were incomplete, and one person had been deprived of their liberty without the required legal authorisation.
The provider's systems did not reliably identify and fix problems. CQC found breaches involving safe care, safeguarding and governance. The overall rating fell from Good at the previous inspection to Requires Improvement. The provider had started improvement work and CQC said it would monitor progress.
People felt respected
People spoke positively about their care. They said they felt safe and respected, and described staff as kind and respectful.
“People told us they felt safe and respected and they had enough to eat and drink.” from the report
Staffing levels
Inspectors found enough care staff to meet people's needs. People did not have to wait for support, and recruitment checks were suitable.
“Appropriate care staff levels were in place to meet the needs of people in the service.” from the report
People's independence
People were supported to make choices and to remain as independent as possible. Staff supported them with the things they wanted help with.
“One person said they valued being able to have as much independence as possible, staff only supported them with things they wanted support with.” from the report
Working with health professionals
The home maintained positive working relationships with local health teams, including GPs, district nurses and therapists.
“All we spoke with were positive about their experience of working with the registered manager and staff team.” from the report
Out-of-date risk assessments
seriousRisk assessments for pressure ulcers, malnutrition and choking were missing or had not been reviewed after people's needs changed. This increased the risk that harm would not be prevented.
“People's risk assessments related to malnutrition and choking were either not in place or had not been reviewed, despite relevant changes in people's physical needs and risks.” from the report
Staff competency checks
seriousChecks that staff were competent to give medicines and administer rescue medicines for seizures had not been kept up to date. This affected opportunities for some people to take part in activities outside the home.
“Records showed three (out of 21) staff's competency in giving medicines had been checked in the year before our inspection and only three staff could administer rescue medicines for seizures.” from the report
Unlawful restriction
seriousOne person was deprived of their liberty for care without the required legal authority. The provider said it sought authorisation after the inspection.
“The provider had deprived a person of their liberty for the purpose of receiving care without lawful authority.” from the report
Weak quality oversight
seriousAudits did not identify the full extent of the problems, and action plans were incomplete or had missed their deadlines. This meant known shortfalls continued.
“The provider's systems to monitor and improve the safety and quality of the service had not always been operated effectively.” from the report
Infection control processes
needs fixingVisitor checks and use of face masks were not always correct. Laundry had built up, creating a potential source of infection.
“Laundry was piled up and the backlog created a potential source of infection.” from the report
- 01Have all risk assessments for choking, malnutrition and pressure ulcers now been reviewed and updated?
- 02How many staff are currently competent to give medicines and administer rescue medicines for seizures?
- 03Does every person subject to restrictions now have the required Mental Capacity Act assessment and Deprivation of Liberty Safeguards authorisation?
- 04What action plan is being used to fix the problems found in the provider's audits, and which actions have been completed?
- 05What checks are now made for visitors, face-mask use and laundry to reduce infection risks?
This was a focused inspection of Safe and Well-led only; the other key-question ratings were carried over from the previous inspection and were not reassessed. This explanation was written from the published report of 6 May 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 London Road
5 rated inspections over 7 years: the service has held its Good rating throughout.
- January 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- April 2020Goodstayed GoodSafe: GoodWell-led: Good
- August 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 20 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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38 live-in carers within about an hour of Gloucestershire
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 £1,030 to £1,360 a week. 31 can care for a couple. 12 years' experience on average.
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
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.