CQC report explained · a residential care home
What the CQC found at Polesworth Group 32 Station Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risks were identified and managed, medicines were given as prescribed, and inspectors found enough staff. Fire drills had taken place, but they were not scenario-based or timed for zone evacuation.
- Effective?
- Good
- Staff had induction and training, people's nutritional and healthcare needs were supported, and the home worked within the principles of the Mental Capacity Act.
- Caring?
- Good
- Inspectors saw kind, considerate and professional care. People were treated with dignity, involved in decisions and supported to maintain relationships with relatives.
- Responsive?
- Good
- Care plans were personalised and staff responded quickly when people needed reassurance or support. People had activities and were supported to follow interests in the home and local community.
- Well-led?
- Good
- Management oversight had improved and audits were used to identify and act on problems. Staff and relatives said they felt supported and able to give feedback.
What inspectors found, January 2020
Rated Good; inspectors found kind, personalised care and clear improvement since the previous Requires Improvement rating, but fire drills needed strengthening.
The inspection was unannounced and took place on 10 January 2020. One inspector spent time with all seven people living at the home, observed care, spoke with staff and managers, reviewed care, medicines and safety records, and later spoke with four relatives.
Inspectors found that people were relaxed, happy and settled. Staff knew people well, treated them kindly, managed identified risks, supported people with medicines, and helped them make choices about food, activities and daily life. The home was clean and well maintained, and there were enough staff to meet people's needs.
All five CQC areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Safe and Well-led had improved from Requires Improvement at the previous inspection, published on 17 January 2019. Inspectors noted that fire drills were not yet scenario-based or timed for zone evacuation.
Kind and settled care
People appeared relaxed and happy with staff. Relatives gave positive feedback about the care and felt involved.
“People were relaxed and happy in the company of staff. People felt settled and secure living at the home.” from the report
Risks managed
Staff knew people's individual risks and how to support them safely. Risk plans had improved and gave staff useful information.
“Risks had been identified and were well managed by staff who knew people well.” from the report
Medicines managed safely
People had their prescribed medicines available and records showed they received them when needed. Trained staff supported people with medicines.
“Medicine administration records showed people received their medicines as prescribed.” from the report
Improved management
The registered manager's oversight had improved since the previous inspection. The provider used checks and audits and acted when they found issues.
“At this inspection this key question has improved and is now rated Good.” from the report
Fire drills needed strengthening
needs fixingFire drills were taking place, but they did not test specific fire scenarios and zone evacuations had not been timed. The provider said future drills would address this.
“Whilst drills took place, these were not fire scenario based and the provider had not timed 'zone evacuation' to ensure enough staff were on shift to achieve this in the desired time.” from the report
No nursing care at end of life
minorThe home did not offer nursing care for people reaching the end of their life. Ask what support would be arranged if your relative's needs changed.
“The home did not offer nursing care for people reaching the end of their life.” from the report
- 01Have you completed the planned scenario-based and timed zone evacuation fire drills, and what did they show?
- 02How would you support my relative if they needed nursing care or end-of-life care?
- 03How would you adapt activities and daily support to my relative's interests, communication needs and level of independence?
- 04How do you review and update a person's risk plan when their needs change, such as mobility or falls risk?
- 05How will my family member and relatives be involved in care decisions and able to give feedback?
This was an unannounced planned inspection covering the care provided, the premises and all five CQC questions; it followed the previous Requires Improvement rating published on 17 January 2019. This explanation was written from the published report of 23 January 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.
What inspectors found, January 2019
Polesworth Group 32 Station Road was rated Requires Improvement; inspectors found kind, personalised care but safety and management checks needed improvement.
This was an unannounced comprehensive inspection on 17 December 2018. One inspector and an expert by experience spoke with people living at the home, relatives and staff. They observed care and reviewed care plans, records, medicines records and quality checks.
The home was rated Good for effective, caring and responsive care. People were supported by kind staff, had personalised activities and care, and were helped with health, food, communication and independence.
The home was rated Requires Improvement for safe and well-led care. Inspectors found risks linked to bed rails, infection control and outdated risk information. Quality checks had not found some of these problems.
The overall rating fell from Good at the previous inspection in May 2016 to Requires Improvement. The manager took some immediate action during or after the inspection, including updating care information and addressing bed rail and equipment concerns.
Kind and respectful staff
People were supported by compassionate staff who respected their privacy and dignity. Staff also encouraged people to make everyday choices.
“Staff were compassionate, kind and caring toward the people they supported.” from the report
Personalised activities
People had individual care and activity plans. Staff recorded what activities people enjoyed and used this information to support their goals.
“People also had personalised activity plans which were used to help people achieve their goals and positive outcomes.” from the report
Health and consent support
People were supported with nutrition, hydration and healthcare appointments. Staff had training in mental capacity and asked for consent before providing personal care.
“Staff had received training in the Mental Capacity Act 2005 and worked within the principles of the Act.” from the report
Safeguarding awareness
Staff understood how to recognise and report abuse. The manager and provider understood their responsibilities when safeguarding concerns were raised.
“Staff had been trained in safeguarding people from abuse and told us they would report any concerns to the registered manager.” from the report
Bed rail risks
seriousOne person was using bed rails without bumpers and there was no risk assessment for possible entrapment injury. The manager took immediate action to use bumpers and consider alternatives.
“Potential risks of entrapment injuries from bed rails used without bumpers had not been assessed.” from the report
Outdated safety information
needs fixingSome care and risk plans did not reflect people's current needs. This included information about an airflow mattress, skin monitoring and thickened drinks.
“Individual risk management plans had not always been updated by the registered manager in a timely way to reflect people's current care and support.” from the report
Infection control
needs fixingInspectors found issues including an uncovered catheter tap and dusty storage areas. These created possible cross infection risks.
“Infection control audits had not identified risks of cross infection that related to one person's catheter care.” from the report
Quality checks missed problems
needs fixingThe home's audits and provider monitoring visits did not consistently find the safety, cleaning and record-keeping problems identified during the inspection.
“There was a system of internal audits and checks undertaken within the home to ensure the quality of the service was maintained, however, these had not been consistently effective.” from the report
- 01What has been changed to assess and manage the risks from bed rails, and how is this checked now?
- 02How do you make sure care plans and risk assessments are updated promptly when a person's needs change?
- 03What action has been taken to prevent cross infection, including catheter care and the storage of cleaning items?
- 04How are medicines stock records checked for accuracy?
- 05How will the new audit format make sure problems are found and corrected promptly?
This was an unannounced comprehensive inspection covering all five key questions; the previous overall rating was Good in May 2016. This explanation was written from the published report of 17 January 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.
Every inspection of Polesworth Group 32 Station Road
3 rated inspections over 4 years: the service has held its Good rating throughout.
- January 2020Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Polesworth Group 32 Station Road →
- January 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Polesworth Group 32 Station Road →
- July 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 January 2011.
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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