CQC report explained · a residential care home
What the CQC found at 59 Woodgrange Avenue
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and reviewed, medicines were safely managed, staff were suitably checked and there were enough staff to meet people's needs.
- Effective?
- Good
- This question was not rated in this inspection.
- Caring?
- Good
- This question was not rated in this inspection, although inspectors found that people were involved in planning their care.
- Responsive?
- Good
- This question was not rated in this inspection, although staff were described as knowing people well and supporting their individual needs and preferences.
- Well-led?
- Good
- Inspectors found regular quality checks, clearer records, staff training and supervision, and a service improvement plan that was reviewed regularly.
What inspectors found, November 2023
Matthew Residential Care Limited - 59 Woodgrange Avenue was rated Good; inspectors found people were safe and involved in their care, with some work still needed on accessible care plans.
This was an unannounced inspection on 28 April 2023. One inspector spoke with one person and four staff, and reviewed care records, medicine records, safety checks and quality monitoring.
The home was rated Good for Safe and Well-led. Inspectors found that risks were assessed and reviewed, medicines were managed safely, staffing was sufficient and staff understood how to protect people from harm.
People were involved in planning their care and activities. The home had improved since the previous inspection, which was rated Requires Improvement in August 2022. Earlier recommendations about managing behaviours and learning from incidents had been acted on.
The inspection followed concerns from a local authority about service quality. Inspectors said those concerns had been addressed. The report does not give ratings for Effective, Caring or Responsive.
Safer risk management
People had individual risk assessments and positive behaviour support plans. These were reviewed when people's needs changed, and staff had guidance on how to respond.
“People's risk assessments were regularly reviewed and updated when there were any changes in their needs.” from the report
Medicines
Inspectors found medicines were stored and recorded safely. Staff had suitable training and their competence had been checked.
“Medicines were safely stored and medicines administration records (MARs)were in good order with no unexplained gaps.” from the report
People's choices
People were involved in care planning, house meetings and activity decisions. Staff supported people to make choices about their daily lives.
“I decide what I want to do, and staff help me.” from the report
Learning from incidents
The home had improved how it recorded accidents and incidents. Managers recorded lessons learned and actions to reduce the chance of problems happening again.
“The records were reviewed by a manager and information about lessons learnt and actions taken to reduce the likelihood of further occurrences were recorded.” from the report
Accessible information
minorCare plans included people's communication needs, but not all information was yet in accessible formats. The report says work had only started on this.
“Some work had commenced on producing these in accessible formats.” from the report
- 01Which parts of my relative's care plan are available in an accessible format, and when will the remaining information be completed?
- 02How are positive behaviour support plans reviewed when a person's behaviour or needs change?
- 03How will you show me that lessons from accidents and incidents have been acted on?
- 04How will my relative be involved in choosing activities and reviewing their care plan?
- 05How will you continue to respond to any concerns raised by the local authority or families?
This was an unannounced inspection focused on Safe and Well-led; Effective, Caring and Responsive were not rated in this report. This explanation was written from the published report of 4 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, October 2022
Requires Improvement; inspectors found kind, personalised care, but safety oversight and leadership improvements were not yet fully established.
This was an unannounced follow-up inspection on 24 August 2022. One inspector spoke with all three people living in the home and three staff members. Records about care, medicines and how the home was managed were also checked.
There had been clear improvement since the previous inspection. Care plans, medicines management, staff training, communication tools and support for activities had improved. People told inspectors they felt safe, well supported and listened to.
The overall rating was Requires Improvement. Effective, caring and responsive care were rated Good. Safe and well-led were rated Requires Improvement because some safety work was not fully developed and leaders could not yet show that improvements would last.
Kind and respectful support
People described staff positively, and inspectors observed warm, respectful and unhurried interactions.
“People received kind and compassionate care from staff.” from the report
Personalised care
Care plans recorded people's needs, preferences, cultural background and aspirations. People were involved in planning their care.
“All care records were transferred to an electronic care planning format.” from the report
Safer medicines practice
Medicine protocols had been updated, staff competency had been checked and records were completed carefully.
“Peoples medicines administration records (MARs) were detailed and completed diligently.” from the report
Choice and independence
People were supported to make everyday choices, maintain relationships, travel, take part in activities and develop independence.
“People were supported to live the life they wanted by staff who knew them well and put them at the centre of decision making.” from the report
Better communication
Picture-based information and a speech app helped people understand information and express their choices.
“The service had introduced a picture book which supported people to make day to day choices.” from the report
Behaviour support still needed specialist input
needs fixingPositive behaviour support plans had improved but did not yet include enough evidence-based approaches and therapies from outside professionals. The home was waiting for a specialist assessment and further development.
“However, we saw that PBS's lacked evidence-based approaches and therapies from external health care professionals such as Speech and Language Therapy (SALT), psychology and psychiatry.” from the report
Lessons from incidents were not clear
needs fixingRecords described incidents, immediate actions and follow-up, but did not consistently explain what the home had learned or how it would prevent similar events.
“However, there was a lack of information about lessons to be learnt following an incident/accident.” from the report
Improvements were not fully embedded
needs fixingInspectors saw better systems, but some work was still in progress. They were not fully assured that the improvements would continue.
“We were not fully reassured that the quality improvements made by the service were fully embedded and will be maintained in the future.” from the report
Some development work remained incomplete
minorPositive behaviour support still needed specialist input, and environmental improvements were ongoing. Staff training was also still being completed.
“PBS's still required further input from behaviour specialists and work in regard to the environment were still ongoing.” from the report
- 01Has an external behaviour specialist now assessed each person's positive behaviour support plan?
- 02How do you record and review lessons from accidents and incidents, and can you explain what changed as a result?
- 03Which staff training is still incomplete, and when will it be finished?
- 04What environmental improvements were planned for completion by November 2022, and have they been completed?
- 05How will managers check that the recent improvements remain in place over time?
This was an unannounced follow-up inspection covering all five key questions, with infection prevention and control also checked under Safe. This explanation was written from the published report of 12 October 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 59 Woodgrange Avenue
5 rated inspections over 7 years: the service has held its Good rating throughout.
- November 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2022Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 31 January 2011.
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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