CQC report explained · a residential care home
What the CQC found at Our House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2024
Rated Requires Improvement; inspectors found serious safety, staffing and management failings, and issued a warning notice.
This was an unannounced focused inspection by two inspectors on 27 November and 4 December 2023. They examined Safe, Effective and Well-led because of concerns about medicines, staffing, training, safeguarding and management oversight. They spoke with people, staff, relatives and professionals, and checked care, medicine, recruitment, training and management records.
The home was not always safe. Inspectors found unresolved fire, electrical, gas and water safety issues, dirty and cold areas, trip hazards, incomplete risk assessments and inaccurate medicines records. Staffing was also short, recruitment checks were incomplete and some staff had not completed enough training.
There were positive findings. People were supported by staff who understood their needs and communication, people could make choices, and staff helped people access healthcare. The provider acted on some issues during the inspection, including cleaning the home, making it warmer and developing additional risk assessments.
The overall rating fell from Good at the previous inspection, published on 1 April 2020, to Requires Improvement. The home breached four regulations. CQC will request an action plan and monitor progress with the provider and local authority.
Staff understood people
Staff understood people's individual needs and communication preferences. People approached staff for help without hesitation.
“People approached staff for support without hesitation and staff responded positively to people's requests.” from the report
Choice and consent
People were supported to make choices and were offered support and consent before assistance was provided.
“People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests.” from the report
Healthcare support
Staff worked with healthcare professionals and helped people access healthcare when needed.
“People had been supported to access health care services when needed.” from the report
Action during inspection
The provider responded to feedback by cleaning the home, making it warmer and adding risk assessments.
“By the second day of the inspection the service had been cleaned, was noticeably warmer and additional risk assessments had been developed.” from the report
Premises and fire safety
seriousInspectors found unresolved fire service recommendations, wedged-open fire doors, damaged flooring and other safety issues. The home was also dirty and cold on the first inspection day.
“Fire doors were propped open with wedges, and flooring was in need of replacement and presented trip hazards in the service's communal spaces.” from the report
Risks were not managed
seriousSpecific risks linked to people's behaviours and one person's ingestion of non-food materials had not been assessed or properly reduced before the inspection.
“The provider failed to ensure risks in relation to people's known care and support needs were adequately mitigated.” from the report
Staffing and training
seriousThere were repeated periods with only three daytime staff, night shifts were sometimes covered by day staff sleeping in, and a third of staff had completed less than half of the required training.
“The reduced staffing levels at Our House were restricting people's opportunities to leave the service and access the community.” from the report
Recruitment checks
seriousSome necessary checks had not been completed. There was no recruitment information for one person and robust references were not recorded for two recently recruited staff.
“The provider had not completed necessary pre-employment checks.” from the report
Medicines records
needs fixingMedicine administration records were not consistently signed or accurately completed. Records about one varying-dose medicine contradicted each other.
“Medicine Administration Records (MARs) had not been consistently completed, staff had not always signed the MAR to show medicines had been administered as prescribed.” from the report
Weak oversight and privacy
needs fixingThe provider's audits had not picked up important safety and premises problems. Inspectors also found that privacy and dignity were not always respected.
“The provider's quality assurance systems were not sufficiently robust.” from the report
- 01Which fire safety, electrical, gas, water and flooring problems identified in the report have now been fully fixed, and can you show us the latest safety records?
- 02How many staff are normally on duty during the day and at night, and how do you make sure people can go out when they wish?
- 03What recruitment checks have now been completed for every staff member?
- 04What proportion of staff have completed the training needed for the people living here, and how are new staff prioritised for training?
- 05How are medicines administration records checked now, including records for medicines given in varying amounts?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 29 February 2024 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, April 2020
Rated Good; inspectors found safe, kind and personalised care, with some building work and records still needing attention.
This was an unannounced inspection on 19 February 2020. Two inspectors spoke with all six people at the home, three staff members and reviewed care, medicine, recruitment and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were supported to have choice, control and independence, with personalised care, safe medicines and enough staff.
Safe and Well-led had improved from Requires Improvement at the previous inspection. The home had fixed earlier problems with medicine records, mental capacity processes, medicine stocks and notifications to CQC. Inspectors still noted that some building work was needed, not all DoLS assessments were complete at the visit, and some staff training was outstanding on the inspection day.
Choice and independence
People were supported to lead their lives, make choices and build everyday skills. Staff encouraged people to do as much as possible for themselves.
“People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.” from the report
Personalised care
Care plans included detailed information about people's needs, preferences, communication and life history. Staff understood how to provide individual support.
“Each person's care plans included a quick reference sheet which held information about their likes, interest and life history.” from the report
Kind and respectful staff
Inspectors saw positive relationships between people and staff. People's privacy, dignity, views and right to refuse care or activities were respected.
“People were treated with consideration and kindliness. Staff were friendly in their approach and offered reassurance and support appropriately.” from the report
Activities and community life
People were supported to take part in activities, go out, keep in touch with relatives and develop meaningful routines.
“Most people went out during the day of our visit. People enjoyed activities in the local community.” from the report
Improved medicines systems
Problems found at the previous inspection had been addressed. Medicine records were complete, assessments were in place and there was no excess stock.
“People's medicines records were now completed as required, people who lacked capacity had assessments in place and no excess stock was held.” from the report
Building design and outstanding work
needs fixingThe environment was not fully designed in line with the guidance referred to in the report. Some areas, including a self-contained flat, still needed improvement or renovation.
“The environment wasn't developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance” from the report
Training records
needs fixingOn the inspection day, some staff had not completed all core training, including fire safety. The provider later sent information saying this training had been completed.
“However, on the day of our visit the staff training record showed some staff had not completed all core training, for example fire safety.” from the report
DoLS assessments
needs fixingThe home had applied for required DoLS assessments, but some had not been completed at the time of the inspection.
“However, not all these had been completed at the time of the inspection.” from the report
Odour in one area
minorThe premises were mainly clean, but inspectors noticed an odour in one area. The manager knew about it and was dealing with it.
“One area had an odour however, the registered manager was aware of this and was in the process of dealing with it.” from the report
- 01What work has been completed on the areas of the building that inspectors said needed improvement?
- 02Have all required DoLS assessments now been completed, and how are they reviewed?
- 03Can you show us the current staff training records, including fire safety training?
- 04How do you check that medicines records remain complete and that there is no excess medicine stock?
- 05How will you support our relative to make choices, build independence and take part in community activities?
This inspection covered the care home, its premises and care provided, and assessed all five CQC questions. This explanation was written from the published report of 1 April 2020 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 Our House
5 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- February 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2020Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- March 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2015
Registered with the Care Quality Commission on 6 February 2015.
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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10 live-in carers within about two hours of Cornwall
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,200 a week. 8 can care for a couple. 12 years' experience on average.
“He had been a little anxious before she arrived, but has since stated that he would be very happy for her to care for him again”
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