What the CQC found at Old Alresford Cottage

People and relatives were generally confident that people were safe from abuse. Staff knew how to raise concerns and felt that management would act on them.

“People told us they felt safe at Old Alresford Cottage and staff had clear guidance about what they must do if they suspected abuse was taking place.” from the report

People, relatives and professionals described staff positively. Inspectors also saw cheerful, gentle and patient interactions.

“Overall people told us staff were kind, caring and friendly and we observed interactions where staff engaged with people in a cheerful and positive manner.” from the report

The provider had corrected the previous recruitment breach. Inspectors found the required checks in the four files they reviewed, apart from one reference oversight that was then addressed.

“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 19.” from the report

Inspectors found significant cleanliness concerns at the first visit, but said the home had much improved by the second visit. The kitchen also had the best standard of food hygiene certificate.

“By the time we made our second visit to the home, the cleanliness of the home had much improved throughout and so we were assured that the registered manager was taking action to address our concerns.” from the report

Some risk assessments were incomplete or conflicting. Inspectors found an alarm mat response taking 11 minutes and records that did not assure them people at nutritional risk were offered enough food and fluids.

“The approach to risk management was inconsistent and records did not always provide assurances about how staff were managing some of the risks to people's health and wellbeing.” from the report

Inspectors found hazards including a loose panel exposing wires, incomplete fire and water safety checks, unfinished legionella recommendations, unresolved lift recommendations and rubbish in the garden.

“There was a significant amount of rubbish stored in the corner of the garden. This included broken glass, sinks, wood and other rubbish.” from the report

Some medicines administration records had unexplained gaps. Records for creams, thickener and as-required medicines did not always show clearly whether medicines had been given or why they were needed.

“We reviewed the medicines administration records (MARs) for July 2022 and found three occasions where there was a gap in the MAR, but no reason for this recorded.” from the report

Audits and quality checks had not identified or resolved all the issues found. Records were sometimes disorganised, and oversight of training, supervision and safety checks was not effective enough.

“The systems in place were not being fully effective at ensuring compliance with the fundamental standards.” from the report

Feedback about staffing levels was mixed. Some people and relatives said staff could be slow to respond, and inspectors observed concerns about responses to call bells and alarm mats.

“Our observations and records did raise some concerns that response times to call bells and alarm mats were not always prompt.” from the report