CQC report explained · a residential care home
What the CQC found at Queensbridge 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, September 2023
Queensbridge House: targeted inspection found improved safe working, but the overall rating remains Requires Improvement and Safe was previously rated Inadequate.
This was an unannounced targeted inspection on 14 June 2023. Inspectors looked only at selected safe working arrangements on the mental health unit. They reviewed four care records, spoke with five staff, and checked policies, records and environmental actions.
Inspectors found that the home had improved its policies, risk assessments, care plans, staff training and safety arrangements. They found no evidence during this visit that people were at risk of harm from the concerns identified at the previous inspection.
This visit was not a full inspection and did not change the service's overall rating. The overall rating remains Requires Improvement. Safe was inspected but not rated because not all parts of that question were reviewed.
Improved care planning
Risk assessments and care plans had been updated. Inspectors said they gave staff clearer guidance about people's needs, observation levels and therapeutic support.
“People's risk assessments and care plans had been reviewed and improved.” from the report
Better staff training
Staff had received extra training on violence and aggression. Staff spoken with understood the relevant policies and how to reduce risks.
“All staff spoken with were clear on the limitations and practices the provider's policies referred to.” from the report
Fire and environmental safety
The home had acted on fire safety recommendations. Personal evacuation plans had been improved, and window restrictions and storage of hazardous chemicals had been addressed.
“People had improved personal emergency evacuation plans (PEEPs) in place, giving information about the support they would need to evacuate the building in the event of a fire.” from the report
Healthcare involvement
Healthcare professionals were involved in developing and monitoring care. A visiting healthcare professional was happy with the care being provided.
“Health care professionals were involved in developing and monitoring people's care.” from the report
The inspection was limited
seriousThe previous Safe rating was Inadequate, but inspectors did not review the whole Safe question or follow up the earlier breaches during this visit.
“At our last inspection this key question was rated inadequate. We have not changed the rating as we have not looked at all of the safe key question at this inspection.” from the report
- 01Which areas of the Safe question were not checked during this inspection, and when will they be reviewed?
- 02What action has been taken to address each breach from the May 2023 inspection?
- 03How are medicines checks being monitored now, and what happens if a problem is found?
- 04How are staff using the new observation, restraint and escalation plans in day-to-day care?
- 05Can you show us how each person's fire evacuation plan and risk assessment is kept up to date?
This was an unannounced targeted inspection of selected Safe arrangements on the mental health unit; it did not assess the other key questions or all areas of Safe, and it did not change the previous overall rating. This explanation was written from the published report of 19 September 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, August 2023
Queensbridge House is rated Requires Improvement overall, with Safe rated Inadequate and serious risks identified.
This was an unannounced focused inspection on 3, 4 and 22 May 2023. Inspectors spoke with people, relatives, staff and visiting mental health professionals. They reviewed care files, medicines records, recruitment records, incident records, complaints and the provider's audits.
Inspectors found serious problems on the mental health unit. Risks linked to people's mental health, forensic histories, restraint, fire, windows, ligature points and hazardous substances were not properly assessed or managed. Medicines were not always stored or recorded safely. Care plans did not always give staff enough information to provide safe, personalised support.
The dementia unit had stronger arrangements. Risks such as falls, pressure ulcers, malnutrition and choking were assessed and included in care plans. People were supported with activities, relationships and choices. However, the home did not have effective systems to monitor quality, record incidents and complaints, or drive improvement.
The overall rating fell from Good at the previous inspection, published in April 2019, to Requires Improvement. The Safe rating fell to Inadequate, while Responsive and Well-led were rated Requires Improvement. Effective and Caring were not inspected, so their previous ratings were used in calculating the overall rating.
Dementia care planning
On the dementia unit, risks and care needs were included in care plans and reviewed when needed. Representatives were involved when people could not express their own views.
“People's care needs on the dementia care unit were reflected in their care/support plans, including information for staff on how to meet these needs.” from the report
Activities and community access
People had opportunities to go out, take part in activities and maintain social, family and religious connections.
“People on this unit were supported to go out most days to support their mental well-being and confidence.” from the report
Staff support
There were enough staff to meet people's needs. New staff were supported through induction and shadowing, and staff received supervision and debriefs.
“There has been more support than I anticipated for me. There is always a senior [member of staff] around to help me.” from the report
Mental capacity and choices
Inspectors found that consent was sought and that decisions made for people were generally made in their best interests and in the least restrictive way.
“People were supported to make choices and to regain control of their lives.” from the report
Clean environment
The environment appeared clean, and relatives also said it was clean when they visited, although they thought it was poorly decorated.
“We found the environment to be clean and people's representatives confirmed the environment was always clean when they visited, although poorly decorated.” from the report
Serious risk management failures
seriousRisks linked to complex mental health needs and forensic histories were not sufficiently assessed or controlled. Environmental risks included fire, windows, ligature points and unsecured hazardous substances.
“Risks associated with people's mental health and complex histories had not been sufficiently assessed and action taken to mitigate risks and keep people safe.” from the report
Unsafe medicines arrangements
seriousSome medicines were stored insecurely. Records and guidance for liquid, controlled and as-required medicines were not always complete or safe.
“The provider had not ensured the proper and safe management of people's medicines which put people at risk of risks associated with medicine errors and the unsafe storage of medicines.” from the report
Incomplete mental health care plans
seriousCare plans did not always explain how staff should support individual risks, distress, restraint, medicines or people's rights. They also did not consistently show people's involvement or preferences.
“People's care was not always planned in a person-centred way and in a way which took into consideration relevant national standards and best practice guidance.” from the report
Limited structured therapeutic activities
needs fixingPeople on the mental health unit had activities and community outings, but inspectors found limited structured and therapeutic activities.
“However, there were limited structured and therapeutic activities.” from the report
Poor complaint records and feedback
needs fixingRecent complaints had been investigated but the records were incomplete. Relatives also said there were limited opportunities to give formal feedback or attend meetings.
“It was therefore not possible to assess if complaints were managed in accordance with the provider's complaints policy or to people's satisfaction.” from the report
- 01What urgent changes have been made to assess and manage ligature, fire, window and hazardous-substance risks?
- 02How are medicines now stored, checked and recorded, including controlled drugs and as-required medicines?
- 03How do current care plans explain each person's risks, de-escalation support, restraint arrangements, medicines and legal rights?
- 04What is the current CQC condition on admissions, and how will you show that any new admission can be supported safely?
- 05How can residents and relatives now give feedback, attend meetings and check that complaints are properly recorded and answered?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 8 August 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.
Every inspection of Queensbridge House
6 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- September 2023Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- August 2023Requires improvementdown from GoodSafe: InadequateEffective: GoodCaring: OutstandingResponsive: Requires improvementWell-led: Requires improvement
- April 2019Goodup from Requires improvementSafe: GoodResponsive: GoodWell-led: Good
- February 2018Requires improvementstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2015Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvement
- June 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 7 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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