CQC report explained · a residential care home
What the CQC found at Prospect House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2021
Rated Requires Improvement; care was kind and responsive, but safety, effectiveness and leadership still needed strengthening after improvements from an inadequate inspection.
Inspectors visited without warning on 5 and 24 August 2021. They spoke with people living at the home, relatives and staff, watched care being provided, and checked care plans, medicines records, training information and management audits.
The home had improved since its previous inadequate rating. People were treated kindly, offered choices and supported with activities. Care planning, staff training and the use of the building had improved. The caring and responsive areas were rated Good.
There were still weaknesses in managing risks, completing health records, checking medicines storage and using audits to find problems. Relatives also reported concerns about changing staff and communication. The home was no longer in breach of regulations and had left Special Measures, but its overall rating was Requires Improvement.
Kind and respectful care
Inspectors found that staff were kind and caring. People’s privacy, dignity, choices and personal information were respected.
“People needs, and preferences were being upheld, people were enjoying their chosen activities.” from the report
Improved staff skills
Staff had completed required and service-specific training. Supervision and checks of staff skills were taking place.
“Staff were suitably competent and skilled. The provider's training plan showed staff had completed mandatory and service specific training.” from the report
More person-centred support
Care plans had been updated with more detailed guidance, including information about epilepsy and behaviour support. People had more access to activities and quieter spaces.
“The quality of information detailed in care plans had been updated and met people's needs.” from the report
Improved choice and control
People were supported to make choices and take part in activities that mattered to them. The home was using its space more effectively.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests” from the report
Some risks continued
seriousIncidents linked to one person’s care continued despite measures intended to reduce the risks. Records about incidents also needed more detail to show that lessons had been learnt.
“incidents associated with one person's care had continued to happen despite control measures to reduce risks being in place.” from the report
Medicine storage checks
seriousSome medicines were stored at temperatures above safe limits. The manager acted when this was found, but existing audits had not identified the problem.
“We found the temperature some medicines were stored at had exceeded safe limits.” from the report
Health records and appointments
needs fixingHealth monitoring records were not always completed when required. A relative also reported that appointments could be late or that staff were not always properly prepared.
“Health and monitoring records were not always consistently completed when required.” from the report
Unreliable management audits
needs fixingAudits were in place but were not always completed monthly and did not identify every shortfall. The inspection said these systems needed further development and embedding.
“Audits were in place; however, they were not always completed monthly and had not identified some shortfalls.” from the report
Complaint communication
minorThe provider had a complaints process, but inspectors recommended clearer communication with complainants about the outcome of their complaint.
“We recommend the provider takes appropriate action to strengthen communication about the outcome of complaints.” from the report
- 01What specific steps are now being taken to prevent the incidents described in the report from happening again?
- 02How do you check medicine storage temperatures every day, and how will you make sure audits identify problems promptly?
- 03How will you ensure health monitoring records are completed and healthcare appointments are attended on time with the right information?
- 04How are you reducing reliance on agency staff and improving consistency for people living at the home?
- 05How will you communicate the outcome of a complaint and keep relatives informed?
This was an unannounced planned follow-up inspection covering all five key questions, including infection prevention and control, after the previous inadequate inspection. This explanation was written from the published report of 8 October 2021 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 2021
Rated Inadequate and placed in special measures; inspectors found people at risk and serious failures in care, staffing and management.
This was an unannounced focused inspection after concerns about safety and management. Inspectors visited on four dates, spoke with people, relatives, staff and a professional, observed care, and checked care plans, medicines, staff files and management records.
They found people were not always protected from avoidable harm. Risks linked to choking, epilepsy, hot drinks, behaviour, staffing and infection control were not managed well. Staff did not always understand people's needs, and some people had limited activities, choice, privacy and community access.
The home had systems intended to check quality, but these checks had not found or fixed important problems. Similar concerns had been found at earlier inspections. The overall rating fell from Requires Improvement to Inadequate, with Safe, Effective, Caring and Well-led rated Inadequate and Responsive rated Requires Improvement.
Medicines storage and checks
Medicines were stored securely, and regular audits and stock checks were in place.
“Medicines audits happened regularly, and action was taken where medicines issues were identified.” from the report
A homely environment
Inspectors found the home was pleasant and homely, and people's rooms had been personalised.
“The environment was decorated in a pleasant way and it felt homely.” from the report
Some independence support
Some staff supported people to develop independence through everyday activities.
“Some kind and caring interactions were seen. Staff did encourage some people to develop their independence.” from the report
Accessible information
Some information was presented in an accessible format to help people understand it.
“We saw easy to understand information on display such as some pictures and photographs to help people understand information.” from the report
People were at risk of harm
seriousRisk assessments were incomplete or not followed. Inspectors found a person at risk of choking left unsupported while eating and a hot drink given without the risk being considered.
“Risks associated with people's care and treatment had not always been identified and managed safely.” from the report
Not enough suitable staff
seriousStaffing levels did not always meet people's needs, and agency staff did not always know people's preferences or have a suitable induction.
“The deployment of staff was not appropriate to meet people's needs.” from the report
Training and care information were inadequate
seriousSome staff had not completed relevant training or did not understand key needs, including choking risks and behaviour support. Important information about epilepsy and health needs was missing or inaccurate.
“Staff lacked the training, competence and skills to support people safely.” from the report
Poor dignity and daily experience
needs fixingPeople had limited meaningful activities and community access. Their privacy, choices and independence were not always respected.
“People were not always supported to follow their interests or encouraged to take part in social activities, or to maintain relationships.” from the report
Complaints were not used to improve care
needs fixingRelatives said they did not feel listened to. Not all complaints were recorded, and lessons from complaints were not consistently used.
“Not all complaints were logged, and information was not available to ensure lessons from complaints had been used to drive improvements.” from the report
Management checks failed
seriousAudits and monitoring did not identify or resolve serious problems. Similar concerns had appeared in earlier inspections and feedback had not always led to change.
“There was a lack of effective management oversight and effective system in place to assess, monitor and improve the quality and safety of the service.” from the report
- 01What immediate changes have been made to prevent choking, scalding, epilepsy and behaviour-related risks?
- 02How many staff are on each shift, and how do you make sure agency staff know each person's needs before providing care?
- 03Which staff have completed the required training, supervision and competency checks, especially for autism, epilepsy, dysphagia and physical intervention?
- 04How are people's choices, privacy, activities, relationships and access to the community now being supported?
- 05What action plan and audit results can you show to demonstrate that the four breached regulations have been addressed?
This was a focused inspection prompted by safety and governance concerns, but its scope was widened to cover all five key questions. This explanation was written from the published report of 10 April 2021 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 Prospect House
7 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- October 2021Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: InadequateResponsive: Requires improvementWell-led: Inadequate
- April 2020Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2019Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- May 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2017Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 7 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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