CQC report explained · a residential care home
What the CQC found at Reach Lower Cippenham Lane
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and neglect, risks were assessed and staffing was sufficient. Inspectors noted that outside waste storage needed closer monitoring, and improvements were made to refrigerated medicine storage.
- Effective?
- Good
- Staff had suitable training, supervision and appraisals. People received appropriate food, drink and healthcare support, and the home followed the Mental Capacity Act.
- Caring?
- Good
- Staff were kind and caring, respected privacy and dignity, and involved people and relatives in care planning and decisions.
- Responsive?
- Good
- Care plans were detailed and personalised. People were supported with communication, relationships, holidays, community activities and their own goals.
- Well-led?
- Good
- Inspectors found a positive workplace culture and effective quality checks. Managers responded to feedback and took action when improvements were needed.
What inspectors found, January 2020
Rated Good; inspectors found kind, person-centred care, with some environmental and medicines issues dealt with during the inspection.
This was a planned inspection on 14 and 20 December 2019. One inspector spoke with people living at the home, relatives, staff and health professionals. They observed care and dining, and checked care plans, medicines, staff records and management records.
The home supported 12 adults with learning disabilities or autism. Inspectors found people were safe, treated kindly and supported to make choices, build independence and take part in activities. Care plans were detailed and personalised, and staff had suitable training and support.
Inspectors found some issues that needed attention. Outside waste storage needed closer monitoring, refrigerated medicines were not stored correctly at first, and oil-filled radiators were being used despite a burns risk. The medicine storage, heating and radiators were improved during the inspection.
The overall rating was Good, and all five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The previous inspection rating was also Good, published on 2 February 2017.
Personalised support
Care plans included detailed information about people's needs, preferences, communication and goals. Staff helped people gain skills and more control over their lives.
“Care plans showed individualised information was recorded. We saw this was comprehensive and specific.” from the report
Kind and respectful staff
People were treated with dignity and respect. Inspectors saw good engagement between staff and people, and received positive feedback from relatives and professionals.
“People were well-groomed and appropriately dressed for the weather.” from the report
Choice and independence
People were supported to make decisions, take positive risks and become more independent. The home also supported contact with relatives, friends and partners.
“The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion.” from the report
Communication and activities
Information was adapted using pictures, photographs, signs and Makaton. People took part in activities, trips, holidays, faith events and community life.
“People were provided with information in the way they could understand.” from the report
Strong management
Managers carried out regular checks and acted on issues. Staff said they felt supported and listened to.
“There was a very positive workplace culture amongst the staff.” from the report
Outside waste storage
needs fixingClinical and general waste storage outside the home needed closer monitoring to reduce possible risks.
“Clinical and general waste storage conditions on the outside of the home required closer monitoring to mitigate any risks.” from the report
Medicines storage
needs fixingRefrigerated medicines were not managed correctly at the start of the inspection. The refrigerator was replaced and temperature monitoring was introduced during the inspection.
“An improvement was made to the management of refrigerated medicines during the inspection.” from the report
Heating equipment
needs fixingOil-filled radiators were being used even though inspectors said they were not recommended because of the risk of burns. They were removed and the central heating was improved.
“The service was using oil-filled radiators at the time of our inspection.” from the report
Service size
minorThe home supported 12 people, which is larger than current best practice guidance. Inspectors said the building design and setting reduced the negative impact.
“The service was a large home, bigger than most domestic style properties.” from the report
- 01How are clinical and general waste areas checked now, and who records those checks?
- 02How are refrigerated medicines stored and how often are temperatures recorded?
- 03What heating equipment is now used, and how is the risk of burns monitored?
- 04How will you support my relative's communication needs, preferences and independence?
- 05How will my relative be supported to keep relationships, attend activities and take part in the local community?
This was a planned inspection of the care home covering all five CQC questions: Safe, Effective, Caring, Responsive and Well-led. This explanation was written from the published report of 29 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, February 2017
Reach Lower Cippenham Lane was rated Good; inspectors found safe, kind and personalised care, with some audit and complaints information to improve.
This was an unannounced comprehensive inspection on 23 December 2016. Inspectors observed care, spoke with managers and care workers, contacted seven relatives or friends, and reviewed care records, staff files and management checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were protected from abuse, risks and medicines were managed safely, and there were enough staff. Staff received relevant training and people were supported with food, healthcare and legal consent arrangements.
People were treated with kindness and respect. Care plans reflected individual needs, preferences and activities. The home had a positive workplace culture, but inspectors recommended wider and more frequent audits. They also noted there was no complaints signage inside the building.
Skilled staff
Staff received ongoing training, supervision and appraisals. Inspectors found strong completion rates in subjects relevant to the care provided.
“We reviewed the training system and saw the service's staff had excellent completion rates in all subjects relevant to their roles.” from the report
Personalised records and support
Care plans included people's individual health, personal and social needs. Daily records described people's behaviour and activities in person-centred detail.
“The daily notes by care workers were detailed, with information recorded which was person-centred.” from the report
Oral health support
The home worked with NHS England on an oral health programme. Inspectors saw oral health plans, teeth-brushing records and referrals to dentists when problems were found.
“had joined up with NHS England in a scheme to promote excellent oral health and hygiene” from the report
Quality audits
needs fixingSome audits had not been completed, including checks of care files, staff files, infection prevention and food hygiene. Inspectors recommended wider and more frequent audits to support ongoing improvement.
“We recommend that the service increases the scope and frequency of audits to drive continuous improvement in the quality of people's care.” from the report
Complaints information
minorThe complaints procedure was available and staff understood it, but there was no sign inside the building explaining how people or visitors could complain.
“there was no signage inside the building to indicate for people or visitors how to make a complaint.” from the report
Family involvement
minorRelatives and friends were involved in care planning where needed, but some said they wanted more involvement in care decisions. Management said they would communicate with those contacts.
“Some family members or friends indicated to us during telephone interviews that they wanted to be more involved with the care.” from the report
- 01What wider and more frequent audits have you introduced since this inspection?
- 02How do you make sure actions from audits are completed and signed off?
- 03How will you involve relatives and friends in care planning and important decisions?
- 04Where can residents and visitors now find information about making a complaint?
- 05How do you make sure changes in someone's health needs lead to prompt medical advice and updated care plans?
This was the first comprehensive inspection and rating under the Care Act 2014, covering all five key questions; the previous planned inspection on 3 September 2013 checked five outcomes and found them compliant. This explanation was written from the published report of 2 February 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 Reach Lower Cippenham Lane
2 rated inspections over 3 years: the service has held its Good rating throughout.
- January 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- February 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 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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