CQC report explained · a residential care home
What the CQC found at 5 St Margaret's Gardens
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2018
Rated Good; inspectors found safe, kind and person-centred care, with some repeated care plan information that could risk records becoming outdated.
This was an unannounced comprehensive inspection on 12 February 2018. One inspector spoke with two people, two staff members and the registered manager. They reviewed care records, staff files, medicines, accidents, complaints, training and quality checks.
The home supported three people with learning disabilities and could support up to four. Inspectors found that people were safe, had enough staff, received medicines as prescribed and were supported to make choices. Staff were trained and people were supported with food, healthcare, activities and relationships.
People were treated with kindness and respect. Care plans reflected people's preferences and were reviewed with their involvement. The home had systems to monitor quality and remained rated Good in all five areas. This was the same overall rating as at the previous inspection.
Safe medicines
Medicines were stored securely, checked regularly and given on time and as prescribed. Extra medicines had personalised guidance explaining when and why they might be needed.
“Records showed that people received their medicines on time and as prescribed.” from the report
Kind support
Inspectors saw staff respond with reassurance when someone became upset. People appeared relaxed and comfortable with staff.
“There was a calm and friendly atmosphere and people appeared relaxed around staff.” from the report
Choice and independence
People helped plan meals, chose how their rooms were decorated and were supported to attend activities and use local services.
“The care plans focussed on supporting people to be as independent as possible.” from the report
Good oversight
The home used audits, meetings and management visits to check quality and identify improvements. Staff training was monitored.
“The provider had systems in place to monitor the quality of the service and identify areas of improvement.” from the report
Repeated care plan information
minorSome information appeared in more than one care plan file. Inspectors said this created a risk that information might not be kept up to date. The issue had also been discussed at the previous inspection.
“Some of the documentation within care plans was replicated in different files.” from the report
- 01How do you make sure repeated information across different care plan files is kept consistent and up to date?
- 02How do you maintain staffing levels and consistency when staff are on training or annual leave?
- 03How would my relative be involved if you were considering a new person for the home?
- 04How will my relative be supported to make everyday choices and stay involved in local activities?
- 05How are medicines reviewed, including any medicines that are only needed at certain times?
This was an unannounced comprehensive inspection covering all five key questions, the premises and the care provided. This explanation was written from the published report of 15 March 2018 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
Rated Good; inspectors found safe, kind and person-centred care, but duplicated care records could cause confusion.
This was an unannounced inspection on 23 August and 5 September 2016. The inspector spoke with three people living at the home, one staff member and the registered manager. They observed care and checked records for three people, medicines and management records.
All five areas were rated Good: safe, effective, caring, responsive and well-led. People said they felt safe and that staff were kind. Inspectors saw respectful, meaningful interactions and found that people were supported to make choices, keep in touch with family and friends, attend activities and access healthcare.
The main weakness was that some care plans, statements and risk assessments were duplicated and not linked. Inspectors said this could confuse staff. They recommended that the home seek advice about developing clearer, detailed care plans.
The home was rated Good overall. At the previous inspection in February 2014, all standards inspected had been met.
People felt safe
People told inspectors they felt safe with staff. Staff understood how to recognise and report abuse.
“The people we asked said they felt safe with the staff.” from the report
Safe medicines and risk planning
Medicine records were signed after medicines were given. Risk assessments covered areas such as staying home alone, moving and handling, and personal care.
“Safe systems of medicine management were in place.” from the report
Respectful care
Staff listened to people, respected their privacy and consulted them before offering support. Inspectors saw warm, meaningful interaction.
“We observed positive interactions between people and staff.” from the report
Choice and community life
People were supported to make daily decisions, keep relationships, attend clubs and day care, go shopping and take part in household tasks.
“People participated in day care centres, joined clubs and went on shopping trips.” from the report
Staff support and oversight
Staff had training, supervision and regular team meetings. The home used feedback, audits and development plans to monitor its work.
“Quality assurance systems to monitor and assess the quality of service were in place and protected people from unsafe care and treatment.” from the report
Duplicated care records
needs fixingSome statements, care plans and risk assessments covered the same needs but were not linked. Inspectors said staff might think they had read the relevant information when they had not.
“This may create confusion as staff may assume they have read the relevant care plan.” from the report
- 01Have the duplicated care plans and risk assessments been combined or clearly linked since this inspection?
- 02How do you make sure staff read the most up-to-date care plan when a person's needs change?
- 03How are staffing levels covered at weekends, when the report says one staff member was sometimes on duty?
- 04How do people living here continue to make choices about their care, activities, meals and healthcare?
- 05How often are care plans and health action plans reviewed now?
This was an unannounced inspection covering all five areas and records for three people living at the home. This explanation was written from the published report of 1 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 5 St Margaret's Gardens
2 rated inspections over a year: the service has held its Good rating throughout.
- March 2018Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- April 2012
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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