CQC report explained · a residential care home
What the CQC found at Onny Cottage
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People felt safe and there were enough staff to meet their needs. Risks, medicines, recruitment, the environment and infection control were checked and managed, although guidance for some as-needed pain relief was missing until the inspection.
- Effective?
- Good
- This key question was not inspected during this focused visit. The report says the rating from the previous inspection was used when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. The report says the rating from the previous inspection was used when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. The report says the rating from the previous inspection was used when calculating the overall rating.
- Well-led?
- Good
- The provider had introduced effective checks and audits, supported staff well and sought people's views. Staff morale was good and the provider worked with health and social care professionals.
What inspectors found, June 2023
Onny Cottage rated Good; inspectors found safe, caring support and improved management, with a medicines shortfall fixed during the visit.
This was an unannounced focused inspection on 23 May 2023. One inspector spoke with five people living at the home, a relative, the provider and two care staff. They also checked care plans, medicines records, recruitment files, training records and health and safety records.
The home was rated Good for Safe and Well-led. People said they felt safe, there were enough staff, risks were assessed and medicines were given by trained staff. The home had also improved its recruitment checks, audits and monitoring since the previous inspection.
The inspection followed notification of an incident in which a person sustained a serious injury. The circumstances of that incident were not examined in this inspection and remained subject to further CQC investigation. The overall rating improved from Requires Improvement at the previous inspection in November 2021.
People felt safe
People told inspectors they felt safe with the staff who supported them. Staff had been trained to recognise and report abuse.
“People felt safe living at the home and with the staff who supported them.” from the report
Enough trained staff
Inspectors found enough staff to meet people's needs safely. Recruitment checks, including references and DBS checks, were completed before staff started.
“There were enough staff to meet people's needs in a safe way.” from the report
Improved oversight
The provider had added checks and audits since the previous inspection. These identified shortfalls in care plans and led to timely action.
“Since the last inspection the provider had introduced further checks and audits to monitor the quality and safety of the service provided” from the report
Supportive atmosphere
Inspectors found staff morale was good and the atmosphere was relaxed. Staff said they received support, training and supervision.
“Staff morale was good and there was a happy and relaxed atmosphere in the home.” from the report
Missing pain relief guidance
needs fixingSome people had as-needed pain relief, but staff did not initially have written guidance explaining when it should be given. The provider addressed this during the inspection.
“Some people were prescribed pain relief on an as required basis however there were no protocols in place to guide staff as to when these should be administered.” from the report
- 01What written protocols are now in place for giving as-needed pain relief, and how are they checked?
- 02What current measures are in place to manage risks of falls and falls from height?
- 03What learning and changes have followed the serious injury incident mentioned in the report?
- 04How are care plan audits and other quality checks followed up when they identify shortfalls?
- 05How will you make sure staffing levels remain sufficient for my relative's needs?
This was an unannounced focused inspection of Safe and Well-led only; the other key question ratings used for the overall rating were carried over from the previous inspection. This explanation was written from the published report of 2 June 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, November 2021
Onny Cottage was rated Requires Improvement; inspectors found kind, personalised care but unsafe recruitment checks and weak quality monitoring.
This was an unannounced inspection on 20 October 2021. One inspector spoke with six people and five staff, and reviewed care records, medicines records, recruitment files and management records.
People said they felt safe and had enough staff to meet their needs. Inspectors found good care in several areas. Staff were kind, respected people's choices and privacy, and supported individual routines, food preferences, healthcare and activities.
There were important weaknesses in management. References had not been obtained before two staff started work. Quality checks had not reliably found or fixed problems with care plans, cleaning records and other actions.
The overall rating was Requires Improvement. Safe and Well-led were Requires Improvement, while Effective, Caring and Responsive were Good. This was the first inspection since the service became registered, but the previous provider's rating had been Inadequate.
Kind and respectful care
People said staff were kind and patient. Inspectors saw staff listening, respecting privacy and supporting people to make choices.
“People told us they were supported by a kind and caring staff team.” from the report
Medicines and staffing
People received their medicines as needed, and inspectors found enough staff to meet people's needs.
“People received their medicines when they needed them from staff who were trained to carry out the task.” from the report
Personalised support
Care planning reflected people's routines, preferences, communication needs and important relationships. People and their representatives were involved in reviews where appropriate.
“People's care plans had been regularly reviewed to ensure they remained reflective of their needs and preferences.” from the report
Activities and family contact
Staff provided activities in the home and supported people to keep in touch with family and visitors during the pandemic.
“Staff had worked hard during the pandemic to ensure people had opportunities for social stimulation.” from the report
Recruitment checks
seriousReferences were missing from two staff files when those staff began employment. This meant the provider could not confirm their previous conduct or suitability at the right time.
“In the two staff files we looked at the provider had failed to obtain references prior to the staff commencing employment.” from the report
Cleaning records and action deadlines
needs fixingCleaning schedules were not always fully recorded, and an infection control action plan did not include a completion timescale. This could mean that actions were missed or delayed.
“Audits on cleaning schedules had failed to identify that these were not being fully completed each day.” from the report
- 01Have references now been obtained before every new member of staff starts work?
- 02How do you check that care plan reviews, including risk assessments for people who manage their own medicines, are completed on time?
- 03How are cleaning tasks recorded and checked each day?
- 04What actions were included in the action plan sent to CQC, and which have now been completed?
- 05How are staff supervision discussions now recorded and followed up?
This was the first inspection of the newly registered service and covered all five key questions, including infection prevention and control; the previous provider's rating had been Inadequate. This explanation was written from the published report of 16 November 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 Onny Cottage
6 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- June 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2021Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- April 2021Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- December 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2021
Registered with the Care Quality Commission on 31 March 2021.
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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