CQC report explained · a residential care home
What the CQC found at Polesworth Group Laurel End
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm, and there were enough staff to meet their needs. Inspectors found weaknesses in some evacuation plans, fire-drill completion, medicine stock recording and fire safety documentation.
- Effective?
- Good
- People's needs were assessed and staff worked with health professionals. Staff supported eating, drinking, medicines and healthcare, although some consent, mental capacity and deprivation of liberty records needed to be made more robust.
- Caring?
- Good
- People said staff were kind and respectful. Staff promoted privacy, dignity, independence, equality and people's choices about who supported them.
- Responsive?
- Good
- Care was personalised and communication needs were understood. People were supported with activities, community links and relationships, and no complaints were reported by the people and relatives spoken with.
- Well-led?
- Good
- Managers used checks and audits to monitor care and acted when they found problems. Inspectors identified that checks had not found the missing floor plan beside the fire panel, but immediate action was promised.
What inspectors found, December 2023
Polesworth Group Laurel End was rated Good; inspectors found kind, personalised care, with some safety and record-keeping improvements needed.
The home provides personal care for up to 9 people with a learning disability or autistic spectrum disorder. The inspection was unannounced and took place on 24 November 2023. One inspector and one Expert by Experience visited.
Inspectors spoke with people, relatives, staff and managers. They observed care and reviewed care plans, risk assessments, medicines records, staff recruitment files, policies, audits and other safety checks. They found people were safe, treated with kindness, supported to make choices and helped to take part in activities and relationships.
The home was rated Good in all five areas: safe, effective, caring, responsive and well-led. Inspectors found some records and safety checks needed improvement. These included personal emergency evacuation plans, staff fire drills, medicine stock records and a missing fire-panel floor plan. The previous overall rating was also Good.
Kind and respectful staff
People described staff as kind, safe and respectful. Inspectors also saw positive interactions between staff and people.
“People were supported by staff who knew them well and were kind toward them.” from the report
Choice and independence
People were supported to make day-to-day decisions and were not unnecessarily restricted. Staff also helped people maintain independence.
“People's freedom was not unnecessarily restricted, and people were not physically restrained.” from the report
Personalised support
Care and communication were tailored to individual needs and preferences. Staff understood non-verbal communication and helped people in ways that reduced distress.
“People's day to day care and support was tailored to meet their individual needs and preferences.” from the report
Good partnership working
Staff worked with relatives and health professionals to support people's health and wellbeing. This included working with GPs, occupational therapists and speech and language therapists.
“The registered manager and care staff worked in partnership with other healthcare professionals involved in people's care.” from the report
Evacuation plans
needs fixingSome personal emergency evacuation plans were not written clearly enough for staff. Management said they would review them.
“However, these were not always robustly written.” from the report
Fire-drill training
needs fixingSome staff had not taken part in fire drills. The manager agreed that all staff would complete a scenario-based drill before the end of December 2023.
“Some staff had not taken part in fire drills.” from the report
Medicine stock records
needs fixingMedicine stock from November 2023 had not been carried forward on the medication records. This meant the current stock could not be accurately checked from those records.
“This meant there was no accurate record of current stock.” from the report
Fire-panel floor plan
needs fixingA floor plan was missing from beside the fire panel. Inspectors said this could cause a delay in an emergency, although a copy was kept in an office folder.
“Whilst a floor plan was available in an office folder, this posed potential delays in an emergency.” from the report
- 01Have all staff now completed the scenario-based fire drill promised before the end of December 2023?
- 02Have every person's personal emergency evacuation plan been reviewed so that staff have clear guidance?
- 03How are medicine stock levels now recorded and checked on medication administration records?
- 04Has the fire-panel floor plan been put in place, and how is this now checked?
- 05How have records about consent, mental capacity and deprivation of liberty been reviewed and improved?
This inspection looked at all five CQC questions, but no judgement was made about end-of-life care because nobody was receiving it at the time. This explanation was written from the published report of 13 December 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, December 2017
Rated Good; inspectors found safe, kind and personalised care, with some improvement plans still being developed.
This was a comprehensive, unannounced inspection on 9 August 2017. The inspector spoke with people living at the home, relatives, staff and a health professional. They also observed care and checked care plans, medicines, training, accidents and quality checks.
The home supported eight people with learning disabilities, although it could accommodate up to nine. Inspectors found enough trained staff, safe medicines practice, detailed care plans and good support with health, food, choice and independence.
People and relatives spoke very positively about the care. Staff were described as kind, respectful and responsive when people's needs changed. The home had a new registered manager, who had taken over in January 2017.
The overall rating was Good, and all five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The home had remained Good since the previous inspection.
Safe medicines
Medicines were stored, given and checked safely. A missed medicines signature was identified quickly and action was taken.
“Medicines were managed, stored and administered safely, in accordance with best practice guidance.” from the report
Responsive support
Staff knew people well and acted quickly when their needs or mobility changed. Activities were tailored to people's interests.
“Staff had time to develop their relationships with people so they had an excellent understanding of people's enthusiasms and interests and what support they needed to develop and follow them.” from the report
Caring relationships
People and relatives described a welcoming, homely atmosphere. Staff supported people to keep in touch with family and friends.
“People and relatives were at the heart of making care decisions and reviewing their care to ensure it continued to meet their needs.” from the report
Personal goals still being developed
minorThe manager had plans to improve how people's aims and outcomes were set and monitored, but these plans were not yet in place at the inspection.
“The registered manager had innovative plans in place to set and monitor outcomes people wanted to achieve but these were not yet in place.” from the report
Feedback response rates
minorThe provider said past questionnaires had received few responses. It was planning more informal ways to hear from people, relatives and staff.
“They had noted low response rates to questionnaires in the past.” from the report
- 01How are you now setting and monitoring the personal goals and outcomes that people want to achieve?
- 02How will you involve my relative in reviewing their care plan and making decisions?
- 03How do you respond when a person's mobility, health or other needs change?
- 04What activities and community opportunities would be available for my relative?
- 05How do you now gather feedback from people, relatives and staff, given the low response to past questionnaires?
This was a comprehensive inspection covering all five areas, and all five ratings were Good; the report says the home had remained Good since the previous inspection. This explanation was written from the published report of 5 December 2017 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 Laurel End
3 rated inspections over 8 years: the service has held its Good rating throughout.
- December 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- December 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- November 2011
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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