CQC report explained · a residential care home
What the CQC found at 31 Sach Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected by staff who understood safeguarding, and there were enough staff. Risk assessments and safety checks were in place, but some additional measures for changes in mood and behaviour were not documented.
- Effective?
- Good
- People had their needs assessed, staff received training and supervision, and people were supported with food, drinks and healthcare. One staff member was not clear about DoLS, so the inspector made a recommendation.
- Caring?
- Good
- Inspectors saw staff providing kind, patient and compassionate support. People's privacy, dignity, choices and independence were respected.
- Responsive?
- Good
- Care plans described people's preferences, communication needs and support needs. People were supported to choose activities and maintain important relationships.
- Well-led?
- Good
- The home was calm and organised, and staff said the registered manager was supportive. Audits, meetings and feedback systems were used to monitor and improve care.
What inspectors found, December 2019
Nonoy Capina - 31 Sach Road was rated Good; inspectors found kind, personalised care, with some improvements needed in risk and medicines records.
This was an unannounced inspection over two days. One inspector spoke with a person using the service, staff and a relative, observed care, and checked care, medicines, recruitment, training and management records.
The home supported four people with learning disabilities and could support up to five. Inspectors found enough staff, safe medicines administration, a clean environment, kind care and support that promoted choice, independence and relationships.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors noted some shortfalls, including incomplete risk information, a missing PRN medicines protocol during the visit and limited staff understanding of DoLS. The PRN protocol was provided after the inspection, and a recommendation was made about DoLS understanding.
Kind and respectful care
Inspectors observed staff being patient and compassionate. People’s privacy, dignity and independence were respected.
“Observations showed people were supported by staff who were kind, patient and compassionate.” from the report
Personalised support
Care plans recorded individual preferences, interests, communication needs and daily support needs. People had choices about their routines and activities.
“Care plans contained people's likes, dislikes, hobbies, interests and daily support needs.” from the report
Safety and cleanliness
There were enough staff, medicines were given safely and on time, and the home was clean.
“The service was clean and free from malodour.” from the report
Promoting independence
Staff supported people to make choices, maintain their skills and become more independent. People were helped to take part in activities and maintain relationships.
“The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion.” from the report
Management oversight
The registered manager used audits, staff meetings and feedback to monitor the service and identify improvements.
“The registered manager completed audits to monitor the quality of the service.” from the report
Risk information was incomplete
needs fixingSome extra measures used when people’s mood or behaviour changed were not written in the risk assessment. This could make it harder for new staff to follow the correct current process.
“However, these were not documented in the risk assessment. This meant new staff joining the service may not be aware of the correct and current process to support people.” from the report
DoLS understanding
needs fixingOne of the two staff members spoken with was not clear about DoLS or whether anyone was subject to one. No one was subject to DoLS at the time, and the inspector made a recommendation for better staff understanding.
“Of the two staff we spoke to, one was not clear on their understanding of DoLS and whether any one at the service was subject to a DoLS.” from the report
PRN medicines protocol
needs fixingA risk assessment did not initially include the required information for PRN, or 'as required', medicines. The manager submitted the protocol after the inspection.
“During the inspection we identified a medicine risk assessment which did not have an "as required protocol"(PRN) for PRN medicines.” from the report
Recording medicine errors
minorOne staff member did not know where a medicine error should be recorded, although they said no error had happened before. The inspector directed them to the medicine error policy.
“However, they were not aware where they should record it as they said it had never happened before.” from the report
- 01How have you updated risk assessments so staff know what to do when a person's mood or behaviour changes?
- 02What training and checks do staff now receive about DoLS and the Mental Capacity Act?
- 03Can you show how PRN medicines and the reasons for giving them are recorded?
- 04What would staff do if a medicine error happened, and where would they record it?
- 05How are people involved in choosing their daily activities, routines and support?
This was an unannounced inspection of all five CQC questions, including the care provided and the home environment; all five ratings remained Good from the previous inspection. This explanation was written from the published report of 7 December 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, June 2017
Rated Good; inspectors found safe, kind and personalised care, with improvements since the previous inspection.
The inspection took place on 23 and 24 May 2017. The first day was unannounced. One inspector spoke with a person, staff, relatives and a health and social care professional. They also observed care and checked care plans, staff records, medicines records and management audits.
The home supported four people at the time, with places for five adults with learning disabilities. Inspectors found staff knew people well, treated them kindly and supported their health, medicines, choices, activities and daily life. They found enough staff, suitable recruitment checks and detailed risk assessments.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. At the previous inspection in August 2015, the home was rated Requires Improvement and had breached two regulations. Inspectors found that improvements had been made, including better risk assessments and notifications to the CQC.
Staff know people well
Staff had worked with people for many years and understood their communication, preferences, health needs and behaviour. This helped them provide familiar and individual support.
“People received care and support from staff who had worked with them for a long period of time and were aware of how to meet their needs.” from the report
Kind and respectful care
Inspectors observed calm and positive relationships. Staff respected privacy and dignity and encouraged people to make choices and take part in daily tasks.
“We saw that staff treated people with respect and kindness, respected their privacy and promoted their dignity and independence.” from the report
Good safety arrangements
Risk plans were detailed and reviewed. Medicines records were complete in the sample checked, staff recruitment checks were in place and staffing levels were considered sufficient.
“People's risks were managed and care plans contained appropriate risk assessments with input from health and social care professionals, which were updated regularly when people's needs changed.” from the report
Personalised activities and choices
People were supported to attend a day centre, follow their interests, take part in trips and receive support for cultural and religious needs. Their preferences were recorded in their care plans.
“Activities available included gardening, going on car journeys, going out on day trips and trips to the cinema.” from the report
Improvements after the last inspection
The home had improved its risk assessments and its understanding of when significant incidents must be reported to the CQC.
“At this inspection we found that improvements had been made.” from the report
Activity schedules were still being developed
minorThe home was working on accessible weekly activity schedules. Ask to see how activities are now explained and planned with each person.
“The registered manager told us they were constantly trying to increase the variety of activities available now that people had less time at the day centre and were still in the process of creating accessible weekly activity schedules.” from the report
- 01Can you show us the current accessible weekly activity schedule and explain how each person chooses activities?
- 02How often are care plans and risk assessments reviewed if someone's health, behaviour or communication needs change?
- 03How do you check that medicines records remain complete and that any pharmacy audit actions are followed up?
- 04How are people and their relatives involved in care reviews, food choices and decisions about activities?
- 05What process do you now follow to report significant incidents to the CQC and other relevant services?
This was a comprehensive inspection covering all five questions; the previous Requires Improvement rating and earlier breaches were from inspections on 14 and 18 August 2015. This explanation was written from the published report of 30 June 2017 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 31 Sach Road
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- December 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 7 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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