CQC report explained · a residential care home
What the CQC found at Reach Sistine Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm. Risks such as choking, epilepsy and behaviours were identified and managed, although thickener used in drinks had been left unsecured in the communal kitchen and was secured after the inspection.
- Effective?
- Good
- People's needs were assessed and staff had suitable training and support. Health professionals were involved when needed, and people received support with eating, drinking and healthcare.
- Caring?
- Good
- Inspectors saw kind and respectful relationships between staff and people. People were offered choices, treated with dignity and encouraged to remain involved and independent.
- Responsive?
- Good
- Care plans were personalised and included people's communication needs, preferences and support needs. People had individual activity programmes, although one relative was disappointed that a holiday had not taken place for two years.
- Well-led?
- Requires improvement
- The home did not have a registered manager and the acting manager had only recently taken on the role. Provider audits were comprehensive, but some care plan reviews and staff supervisions were overdue, and some relatives wanted better communication.
What inspectors found, March 2019
Rated Good overall; inspectors found safe, kind and responsive care, but leadership and communication needed improvement.
This was an unannounced inspection on 5 March 2019. Two inspectors spoke with people, staff and managers, observed care, looked around the home and reviewed care records, medicines, recruitment files and safety records. They also contacted relatives and health professionals.
The inspectors found that people were safe and received effective, caring and responsive support. Risks were assessed, medicines were generally managed safely, staffing was flexible, and people were supported with their health, communication, activities and choices.
The overall rating was Good. The ratings for Safe, Effective, Caring and Responsive were Good. Well-led was rated Requires Improvement because there was no registered manager, some care plan reviews and staff supervisions were overdue, and communication with relatives was not always strong.
Managing risks
Risks linked to people's health, behaviour, eating and drinking were identified and had clear plans to reduce them. Staff knew how to support people safely.
“Risks to people were identified with clear strategies in place to mitigate the risks.” from the report
Kind relationships
Inspectors saw people relaxed and comfortable with staff. Staff supported people with kindness, dignity and appropriate encouragement.
“We observed positive relationships between people and staff. People were relaxed and were seen to be laughing and joking with staff.” from the report
Activities and choice
People had person-centred activity programmes and were supported to go out, attend college, shop and take part in activities they enjoyed.
“Each person had a person-centred programme of activities.” from the report
Provider oversight
The provider carried out regular audits covering areas such as medicines, care plans, health and safety and infection control. An action plan was used to track improvements.
“The providers audits viewed were comprehensive and provided effective monitoring.” from the report
No registered manager
needs fixingThe home had been without a registered manager since August 2018. An acting manager had recently taken on the role, with the arrangement due to be reviewed after three months.
“The service did not have a registered manager since August 2018.” from the report
Communication with relatives
needs fixingSome relatives said they had limited involvement in care plans and did not know which staff member was their relative's keyworker. Feedback also mentioned communication about meals and care planning.
“Some relatives told us they had little involvement in care plans and some were not aware which staff member acted as a keyworker.” from the report
Overdue reviews
needs fixingSome care plan reviews and staff supervisions were overdue. The provider had identified this through its own audits and was addressing it.
“Some reviews of care plans and staff supervisions were overdue.” from the report
Choking risk control
seriousThickener used for people at risk of choking was left in the communal kitchen. The provider confirmed after the inspection that it had been made secure.
“During the inspection we saw that a thickener used in drinks for people at risk of choking was left out in the communal kitchen.” from the report
- 01Who is currently responsible for managing the home, and what is the timetable for registering the acting manager?
- 02How will I be involved in my relative's care plan reviews and receive updates about changes in their care?
- 03Who is my relative's keyworker, and how often will that person communicate with me?
- 04How do you keep thickener and other items linked to choking risks secured?
- 05How are overdue care plan reviews and staff supervisions being brought up to date?
This was an unannounced inspection of the whole care home, including the premises and care provided, and it assessed all five CQC questions. This explanation was written from the published report of 27 March 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 Reach Sistine Manor
4 rated inspections over 3 years: the service has improved, from Inadequate to Good.
- March 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016Goodup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2016Inadequatestayed InadequateSafe: Requires improvementEffective: InadequateCaring: InadequateResponsive: Requires improvementWell-led: Inadequate
- November 2015InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- July 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- October 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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