CQC report explained · a residential care home
What the CQC found at 18 Boundary Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People said they felt safe, and staff understood safeguarding procedures. Risk assessments supported positive risk-taking, although inspectors found that some guidance for managing frustration and anxiety was not effective.
- Effective?
- Good
- Staff had mandatory training, regular supervision and support from healthcare and social care professionals. People were supported with meals, appointments, annual health checks and hospital passports.
- Caring?
- Good
- People said staff were kind and caring. Inspectors found that people were involved in decisions, treated with dignity and supported to develop confidence and independence.
- Responsive?
- Good
- Care plans reflected people's needs, communication, preferences and routines. People took part in activities, maintained relationships and were supported to raise concerns.
- Well-led?
- Good
- Quality checks, audits, action plans, staff meetings and supervision were in place. The report says the home was consistently managed and promoted high-quality, person-centred care.
What inspectors found, April 2019
Ordinary Life Project Association - 18 Boundary Road was rated Good; inspectors found safe, kind and personalised care, with some support guidance needing review.
This was a scheduled inspection on 5 March 2019. One inspector reviewed information held by the CQC, contacted people, staff and professionals, looked at records for all three people, checked staffing rotas and inspected the home.
The home supports three people with learning disabilities. People said they felt safe and that staff were kind. Inspectors found safe medicines management, person-centred care plans, support for healthcare needs and opportunities for people to build independence and make their own choices.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The report says this means legal requirements were met for safety, people's outcomes were consistently good, and care was consistently managed and person-centred.
Safe medicines
Inspectors found that medicines were managed safely. Records supported self-administration where people were assessed as able to do this.
“Medicine Administration Records (MAR) were signed by competent staff when medicines were administered.” from the report
Growing independence
People had become more confident and independent at home and in the community. Staff supported positive risk-taking rather than restricting people unnecessarily.
“The abilities and skills of people had improved since our last inspection.” from the report
Personalised support
Care records described individual preferences, communication needs, routines and the support each person wanted. People were involved when their records were reviewed.
“Support plans were reflective of people's needs and described the person's preferences.” from the report
Kind and respectful staff
People said staff were kind and caring. Inspectors found that privacy, dignity, choice and involvement in decisions were respected.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Quality monitoring
The home used audits and action plans to check care, medicines and infection control. Staff also received feedback and regular supervision.
“Systems were in place to assess and monitor the quality of service delivery.” from the report
Some support guidance was not effective
needs fixingDaily records showed that staff followed guidance for one person's frustration and anxiety, but reports indicated that the approach was not working. Referrals had been made to healthcare professionals for further advice.
“Daily notes confirmed guidance was followed but reports indicated these instructions were not effective.” from the report
- 01What new advice was received from healthcare professionals about support for frustration, anxiety or fixated ideas?
- 02How do you check that revised support guidance is working for the person concerned?
- 03How is staffing cover arranged during the day and at night, and what support is provided by the additional staff rostered three times a week?
- 04How are people involved in completing their advanced decision documents and planning for future care?
- 05How have funding constraints and recruitment or rota changes affected the support available?
This was a scheduled inspection of all five areas of the home, using records for all three people, feedback from people and staff, and a check of the property and staffing arrangements. This explanation was written from the published report of 11 April 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, September 2016
Rated Good overall; inspectors found safe, kind and person-centred care, but noted staffing gaps and weaknesses in medicine storage checks.
The inspection was unannounced and took place on 3 March 2016. One inspector spoke with all three people living at the home, the area manager and two staff members. The inspector also observed care and checked support, decision-making and management records.
All five areas were rated Good. People said they felt safe, were treated with respect and were involved in decisions about their care, meals and daily activities. Staff understood people's risks and support plans gave guidance about their needs.
The report also found some issues. There were staff vacancies and relief staff were being used. Medicine cabinet temperature checks were not done when showers were being used, and some records of meetings were not available. A registered manager was on extended leave, with the area manager taking on management responsibilities.
People felt safe
All three people told the inspector they felt safe. Staff knew how to report abuse and how to reduce identified risks.
“The three people we asked told us they felt safe living at 18 Boundary Close.” from the report
Support for independence
People made meals, took part in household tasks and attended clubs, work and community activities. Staff supported people without taking away their choices.
“People were assisted by staff with independent living such as cleaning of bedrooms and preparing meals.” from the report
Respectful care
Staff consulted people before offering support and respected privacy, including knocking before entering bedrooms.
“Members of staff were respectful and consulted people before they offered support.” from the report
Personalised support
Care and support plans described people's routines, communication preferences, health needs and the help they wanted.
“Care plans reflected people's current needs and gave the staff guidance on meeting people's needs.” from the report
Staff vacancies
needs fixingThe home had staff vacancies and used relief staff to cover some shifts. The report says the relief staff were known to people, but families should check whether staffing is now stable.
“People said they had the attention they needed but there were staff shortages.” from the report
Medicine cabinet temperature
seriousThe medicine cabinet was in the shower room. Its temperature was not checked during or soon after showers, so medicines might have been stored above the recommended safe temperature.
“This meant the temperature may be above the safe recommended levels for medicines.” from the report
Relief staff training
needs fixingThe report records that relief staff did not have refresher training to update their knowledge and skills. This was raised with the area manager during feedback.
“However, relief staff said they did not have refresher training to update their knowledge and skills.” from the report
Missing meeting records
minorThe inspector did not see copies of some tenant and team meetings. The registered manager later said further meetings had taken place.
“We did not see any other copies of tenants meeting.” from the report
- 01How are staff vacancies being covered now, and how often are relief staff used?
- 02What changes were made to check the medicine cabinet temperature during and after showers?
- 03What refresher training do relief staff receive, and how is completion recorded?
- 04How are tenant and team meetings recorded and followed up now?
- 05Who is responsible for managing the home when the registered manager is away?
This was an unannounced inspection of the overall service, covering all five CQC questions and including observations, discussions with all three people living at the home, and checks of care and management records. This explanation was written from the published report of 3 September 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 18 Boundary Road
2 rated inspections over 3 years: the service has held its Good rating throughout.
- April 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 16 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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