CQC report explained · a residential care home
What the CQC found at Luton Council Respite and Shared Lives Service
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 risks were not fully assessed or kept up to date. Medicines and enteral feeding were not always managed safely, although the provider took action during the inspection.
- Effective?
- Requires improvement
- Consent records and care plans were inconsistent, and staff competence for enteral feeding had not been assessed. Staff did support people with food, drinks, healthcare and communication needs.
- Caring?
- Good
- The report does not give a separate rating for this question. Inspectors observed positive interactions and people said staff kept them safe.
- Responsive?
- Good
- The report does not give a separate rating for this question.
- Well-led?
- Requires improvement
- Checks and audits did not identify important problems with care plans, risks, medicines and enteral feeding. Staff also said their concerns and ideas were not always acted on quickly enough.
What inspectors found, November 2023
Rated Requires Improvement; inspectors found risks, medicines and management systems that were not always handled safely.
The inspection took place on 22, 25 and 29 September 2023. One inspector visited the office, spoke with people, relatives, staff and shared lives carers, and checked care records, medicines records, staff files and management records. The report covers both the respite care home and the shared lives service.
Inspectors found positive relationships between staff and people. People said they felt safe, received enough food and drink, and were supported to access health services. However, risks, care plans, medicines and staff skills for enteral feeding were not always managed safely. Staffing plans for the respite service were also not always effective.
The service was rated Requires Improvement overall. Safe, Effective and Well-led were each rated Requires Improvement. The previous overall rating was Good, published in October 2018. CQC identified breaches about safe care and treatment and good governance, and will monitor the provider's improvement plan.
People felt safe
Staff understood safeguarding procedures and knew people well. People and relatives told inspectors they felt safe.
“People were kept safe from abuse because staff knew them well and understood how to protect them.” from the report
Positive staff relationships
Inspectors saw positive interactions between staff and people. People said staff knew their needs.
“We observed positive interactions between people and staff and people told us they felt safe.” from the report
Food and drinks
People were supported to choose meals and drinks and were offered regular drinks and snacks.
“People received support to eat and drink enough to maintain a balanced diet.” from the report
Partnership working
Staff worked with health and social care professionals to support people's health and achieve positive outcomes.
“Staff we spoke with during the inspection described how they had worked with multidisciplinary health and social care professionals” from the report
Risks and care plans
seriousSome risks were not identified or reduced, and care plans and risk assessments contained inconsistent or out-of-date information.
“People were at risk of harm because risks were not always fully assessed, and care plans contained inconsistent information.” from the report
Medicines and enteral feeding
seriousMedicines care plans were not always accurate. There was no clinical monitoring or evidence that staff competence had been checked for enteral feeding.
“Medicines were not always managed safely.” from the report
Staffing plans
needs fixingVacancies in the senior team affected rota planning. Staff deployment was not always planned effectively for the people attending the respite service.
“There are enough staff, but staff planning is poor.” from the report
Management checks
seriousGovernance systems and audits did not identify the problems found during the inspection. Staff said concerns and ideas were not always acted on quickly or sustained.
“Governance processes were not effective at ensuring the quality and safety of the service.” from the report
- 01What has been changed to make sure my relative's care plan and risk assessments are accurate and kept up to date?
- 02If my relative needs enteral feeding, which staff are currently assessed as competent, and how is their competence checked?
- 03How are medicines given safely, including medicines mixed with food, and what pharmaceutical advice has been obtained?
- 04How are staffing rotas planned for the mix of people attending the respite service, and what has been done about the senior team vacancies?
- 05How will you show that staff concerns and feedback are acted on and that improvements are sustained?
The inspection covered the respite care home and the regulated personal care provided through the shared lives service, with ratings reported for Safe, Effective and Well-led; separate ratings for Caring and Responsive are not given. This explanation was written from the published report of 21 November 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 2021
Inspected but not rated; inspectors found strong infection control, but were only somewhat assured about regular staff COVID-19 testing.
This was a targeted inspection on 5 February 2021. It looked at infection prevention and control during the coronavirus pandemic. The inspection was announced.
Inspectors found the home was clean, well ventilated and cleaned several times a day. Staff used personal protective equipment correctly. Admission arrangements, social distancing, shielding and plans for possible COVID-19 symptoms were in place.
Inspectors were somewhat assured that staff received regular COVID-19 testing. They signposted the provider to further resources. After the inspection, the provider said it had received funding for lateral flow testing when staff entered the building.
The home was inspected but not rated. This means the report does not give a Good, Requires improvement or Inadequate rating. The shared lives part of the service was not inspected.
Clean and ventilated home
The home was very clean and well ventilated. Key areas were cleaned several times a day, and people had their own bathrooms.
“The home was very clean and well ventilated. Key areas were cleaned several times a day.” from the report
Safe admissions
The admission process had been changed to reduce the risk of infection. There were plans for people who developed COVID-19 symptoms during their stay.
“The registered manager had adapted the home's admission processes to prevent the spread of potential infections.” from the report
Correct PPE use
Inspectors saw staff using personal protective equipment correctly. Staff had received training and people were supported to understand why it was needed.
“We observed staff wearing personal protective equipment (PPE) correctly. Staff received training in relation to PPE.” from the report
Infection monitoring
The home monitored important infection control measures and had not experienced any COVID-19 cases during the pandemic up to the inspection.
“The registered manager was monitoring key aspects of infection protection control (IPC) to promote people's safety.” from the report
Regular staff testing
needs fixingInspectors were not fully assured that staff received regular COVID-19 testing. The provider was signposted to resources, and later said it had received funding for lateral flow testing when staff entered the building.
“We were somewhat assured about the provider ensuring staff received regular COVID-19 testing.” from the report
- 01How often are staff tested for COVID-19 now, and is testing carried out when staff enter the building?
- 02What happens if a person develops COVID-19 symptoms during a short stay?
- 03How are people and families told about the home's current infection prevention arrangements?
- 04What evidence can you provide that staff are trained to use PPE correctly?
- 05What information can you provide about the quality of care in areas not assessed by this inspection?
This was a targeted inspection of infection prevention and control in the respite care home; the shared lives service and the other four key questions were not inspected. This explanation was written from the published report of 2 March 2021 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 Luton Council Respite and Shared Lives Service
2 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- November 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Luton Council Respite and Shared Lives Service →
- March 2021Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Luton Council Respite and Shared Lives Service →
- October 2018GoodSafe: GoodEffective: GoodWell-led: Good
- November 2016
Registered with the Care Quality Commission on 14 November 2016.
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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