CQC report explained · a residential care home
What the CQC found at Reach Vale Road Chesham
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risks, accidents, safeguarding concerns, medicines and infection control were managed. Staffing levels were maintained, but the home had five vacancies and used regular agency staff.
- Effective?
- Good
- People's health, nutrition and access to health professionals were supported. Staff had relevant training, although supervision meetings were not taking place as often as the provider's policy required.
- Caring?
- Good
- Staff were kind, caring and supportive. They offered choices, promoted independence and used pictures, objects and signs to help people communicate.
- Responsive?
- Good
- Care plans gave detailed guidance about people's individual needs and choices. Activities were available, but inspectors noted a recent decline in community activities which the manager was addressing.
- Well-led?
- Good
- The manager was described as approachable and committed. Record keeping and auditing had improved, although some completed actions had not been formally signed off.
What inspectors found, December 2017
Rated Good; inspectors found safe, kind and well-planned care, but staffing vacancies and some record checks needed attention.
Inspectors visited unannounced on 28 and 29 November 2017. They spoke with people, relatives, staff and health professionals. They observed care and reviewed care plans, medicines records, staff files and other records.
The home supported five people with learning disabilities in a building registered for six. Inspectors found that people were safe, their health and nutritional needs were met, and staff were kind and understood people's needs. Care plans and records had improved since the previous inspection.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. This means the inspection found a reliable standard of care across these areas at the time of the visit, although some improvements were still being worked on.
Kind and respectful staff
People had positive relationships with staff. Staff offered choices, gave people time to decide and promoted privacy, dignity and independence.
“People were supported by staff who were kind, caring, engaging and supportive.” from the report
Improved care planning
The updated care plans gave staff detailed instructions about people's risks, needs and support. Records had improved since the previous inspection.
“At this inspection we saw good progress had been made in developing person centred care plans.” from the report
Safe care and medicines
Risks were assessed and reviewed. Inspectors found appropriate medicine systems, with no gaps in the medicine administration records they checked.
“There were safe medication administration systems in place and people received their medicines when required.” from the report
Good communication support
Staff used pictures, objects, signs and communication passports to help people understand information and take part in decisions.
“People were provided with aids and pictures to promote their communication and involvement in their care.” from the report
Staff vacancies
needs fixingThe home had five vacancies, including a deputy manager role. Required staffing levels were maintained using overtime and regular agency staff, but the vacancies made it harder for the manager to develop the service.
“The home had five staff vacancies which included a deputy manager position that they were attempting to recruit into.” from the report
Fewer community activities
needs fixingInspectors found that access to community activities had recently declined. The manager recognised this and said it was being addressed.
“People had access to activities and whilst there had been a decline in people accessing community activities this was recognised and being addressed.” from the report
Staff supervision
needs fixingOne-to-one supervision was not happening as often as the provider's policy required. Inspectors also found no evidence that issues raised in one supervision record had been addressed.
“The registered manager recognised supervisions were not taking place at the frequency outlined in the provider's policy.” from the report
Audit actions
minorThe home had improved its audits, but some actions marked as completed had not been signed off. The provider planned to improve how actions were reviewed.
“It was not clear how these were reviewed and signed off as some actions completed had not been signed off as completed.” from the report
- 01How many of the five staff vacancies, including the deputy manager role, have now been filled?
- 02How do you make sure agency staff know each person's needs and provide continuity of care?
- 03What community activities are currently available, and how do you make sure each person can take part?
- 04How often do staff now receive supervision, and how are issues raised in supervision followed up?
- 05How do you check and formally sign off actions identified through audits?
This was an unannounced inspection of the whole service, including the premises and care provided, and it assessed all five CQC questions. This explanation was written from the published report of 21 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.
What inspectors found, December 2016
Rated Requires Improvement; inspectors found safe, kind and responsive care, but serious gaps in decision-making, records and checks.
Inspectors made an announced visit on 17 November 2016. They spoke with a resident, staff, relatives and a college tutor. They observed care and reviewed care plans, medicine records, staff files and other records.
The home was rated Good for Safe, Caring and Responsive. People were kept safe, medicines were given as prescribed, staff were kind, and people had access to activities and health support.
The home was rated Requires Improvement for Effective and Well-led. Decisions were not always made under the Mental Capacity Act. Care plans and other records were unclear or incomplete, and checks did not cover all areas of care.
The provider breached two regulations. CQC required the provider to send a report explaining what it would do, and said it would check that action was taken.
Safe staffing and medicines
Inspectors found enough staff to meet people's needs, with extra staff available for appointments and activities. Medicines were given as prescribed and records checked had no gaps.
“People's medicines were appropriately managed.” from the report
Activities and health support
People had access to college, community activities and outings. Staff supported health appointments and monitored people's health and weight.
“People had access to activities and were supported to participate in the community.” from the report
Accessible manager
Relatives and staff described the manager as approachable and available. Inspectors also saw the manager involved in day-to-day care.
“The manager's door is always open and we can talk to them at any time” from the report
Mental capacity decisions
seriousSome care and treatment decisions were made without clear best-interest meetings or evidence that the Mental Capacity Act had been followed. This was a breach of Regulation 11.
“People who were deemed to not have capacity were given the flu jab and had bloods taken without an MCA in place.” from the report
Poor records and care plans
seriousCare plans did not give enough detail about the support each person needed. Records about risks, meals, activities and handovers were difficult to use, and some information was contradictory.
“People's care plans were disorganised and information inaccessible.” from the report
Incomplete quality monitoring
seriousThe provider had some monitoring visits and was introducing further audits, but it was not checking all areas of care and practice. This was a breach of Regulation 17.
“However a health and safety, infection control and other audits of practice were not established or taking place.” from the report
Limited accessible involvement
needs fixingInformation was not consistently provided in formats people could use. Pictures, objects and communication methods were still being developed and were not used consistently.
“Information for people was not available in a user friendly, accessible format and therefore their involvement within the home was limited.” from the report
- 01How are you now making and recording best-interest decisions for people who may lack capacity?
- 02How have you rewritten care plans so they clearly describe the support each person needs?
- 03How do you check that risk, meal, activity and handover records are complete and easy for staff to use?
- 04Which quality audits are now in place for health and safety, infection control, medicines and accidents?
- 05How do you help residents understand care plans, complaints information and meetings using pictures or other communication aids?
This was an announced full inspection covering all five key questions, with observations, discussions and checks of care, medicines, staff and service records. This explanation was written from the published report of 24 December 2016 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 Vale Road Chesham
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- December 2017Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- February 2013
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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