CQC report explained · a residential care home
What the CQC found at Mr & Mrs A H Akbarally
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2019
Mr & Mrs A H Akbarally was rated Good; inspectors found safe, kind and personalised care across all five areas.
This was a planned comprehensive inspection on 15 May 2019. One inspector spoke with both people living at the home, two relatives and three staff. They also reviewed care records, staff files, medicines information and management records.
The home supports up to three people with learning disabilities. Two people lived there during the inspection. Inspectors found enough trained staff, well-managed risks, safe medicines systems and a clean home. People were supported to make choices, stay active, attend healthcare appointments and take part in activities they enjoyed.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Safe had improved from Requires Improvement at the October 2016 inspection because earlier concerns about recruitment checks, medicine protocols and safety checks had been remedied.
Safe medicines
Inspectors found that medicines were given as prescribed and the records were complete. Guidance was also available for medicines given when needed.
“People received the medicines they required and medicine administration records (MARs) were correctly filled out with no gaps.” from the report
Personalised care
Care plans covered people's lives, preferences, interests and personalities. Staff knew the two residents very well and supported their individual choices.
“Each care plan had a detailed record of the person's life, family, hobbies, preferences, religion, objectives and personality.” from the report
Kind and respectful support
People were treated with dignity and involved in decisions about their care. They were encouraged to do as much as possible for themselves.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Activities and inclusion
People took part in activities, holidays and trips that suited their interests. The home also supported links with local groups, day centres and a church.
“People had access to a wide range of activities, holidays and trips into town.” from the report
Close management
The managers were present in the home throughout the day and knew the residents well. Inspectors found effective quality checks and accurate records.
“The two managers were present in the home all day and knew both people very well.” from the report
Inspectors raised no specific concerns in this report.
- 01How would you keep the same level of personalised care if the number of residents or staff changed?
- 02How often are my relative's risk assessments and care plans reviewed and updated?
- 03How would you support my relative to choose activities, holidays and trips that match their interests?
- 04How do you check that medicines records remain complete, including medicines given when needed?
- 05How are relatives involved in care reviews, complaints and decisions about changes to the home?
This was a scheduled comprehensive inspection covering all five key questions; the previous overall rating was Good, published in October 2016. This explanation was written from the published report of 24 May 2019 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, November 2016
Mr & Mrs A H Akbarally was rated Good overall; inspectors found kind, personalised care, but Safe Requires Improvement.
Inspectors visited on 19 October 2016 and spoke with all three people living at the home, staff, the provider and an external professional. They observed care, shared lunch with people and reviewed care, medicines, staff and management records.
People appeared happy and at ease. Staff were kind, knew people's needs well and supported choice, health, activities, relationships and independence. The home was rated Good for Effective, Caring, Responsive and Well-led.
Safe was rated Requires Improvement. Recruitment checks were not always repeated after a staff member returned following a break, written guidance was missing for some as-needed medicines, and some safety repairs were not completed promptly. The home arranged action on the outstanding issues within 24 hours of the inspection.
Kind relationships
Staff knew people's personalities and support needs well. Inspectors saw frequent, positive engagement and a relaxed atmosphere.
“People were treated with kindness and positive, caring relationships had been developed.” from the report
Personalised support
Care plans included people's backgrounds, preferences, relationships and activities. Staff supported people to remain involved in their community and develop daily living skills.
“People received individualised care that was tailored to their needs.” from the report
Choice and rights
People were supported to make everyday choices and were involved in decisions about their care and the home. Consent and mental capacity processes were followed.
“People exercised choice in day to day activities.” from the report
Skilled staff
Staff had training and experience in areas including medicines, first aid, food hygiene, infection control and person-centred care.
“Staff were sufficiently skilled and experienced to care and support people to have a good quality of life.” from the report
Recruitment checks
seriousRobust recruitment procedures were not always followed. A new criminal records check had not been completed when one staff member returned after an 18-month break, although evidence of a DBS check was supplied within 24 hours.
“Robust recruitment processes were not always followed. Therefore, people could not always be assured staff were safe to work at the home.” from the report
As-needed medicines guidance
seriousThere was written guidance for as-needed pain relief, but not for other as-needed medicines. This meant staff did not have complete written instructions.
“Protocols were not documented for other PRN medicines.” from the report
Fire door repair
seriousOne fire door still lacked the strips and seals recommended by the fire service. The outstanding work was arranged within 24 hours of the inspection.
“At the time of our inspection there was one fire door that did not have the strips as recommended by the fire officer.” from the report
Quality checks
needs fixingAudits and checks took place, but they did not always identify problems or make sure action was taken promptly. Examples included electrical testing and missing guidance on duty of candour.
“Despite the checks taken place monitoring systems had not always ensured action was taken for shortfalls.” from the report
- 01What systems are now in place to make sure all staff recruitment and repeat checks are completed before they work with people?
- 02What written protocols are now available for each person's as-needed medicine, and how are staff checked on their use?
- 03Has the fire door work been completed, and how are repairs tracked to make sure they are done promptly?
- 04How do your quality checks identify shortfalls and confirm that action has been completed?
- 05How will you continue to support each person's choices, community activities and independent living skills?
This was an announced inspection of the overall service, covering Safe, Effective, Caring, Responsive and Well-led. This explanation was written from the published report of 23 November 2016 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 Mr & Mrs A H Akbarally
2 rated inspections over 2 years: the service has held its Good rating throughout.
- May 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 9 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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