CQC report explained · a residential care home
What the CQC found at 90 Capel Gardens
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2019
Rated Good; inspectors found kind, safe and personalised care, with some records and management arrangements still being improved.
This was an unannounced, comprehensive inspection on 5 December 2018. One inspector observed care, spoke with managers and staff, contacted relatives and a social care professional, and checked care records, staff files, audits and policies.
The home supported up to six people with learning disabilities. Five people were living there at the inspection. Inspectors found that people were safe, treated with kindness and supported by staff who knew their needs and preferences.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. There were no breaches of the legal regulations at this inspection.
The home was being managed by an interim manager after the registered manager had left. The provider was recruiting a permanent manager. Some improvements were still planned, including work on staff training, supervision, the building and end of life records.
Personalised care
Care plans described people's needs, preferences and routines. Staff used this information to provide consistent support.
“People's care plans were up to date and personalised.” from the report
Kind and respectful staff
Inspectors saw friendly and respectful interactions. Staff supported privacy, dignity, communication and independence.
“People were treated with kindness from staff who knew them well and understood their individual needs.” from the report
Safe medicines
Medicines were stored, administered and recorded safely. Staff competency had been checked and medicines were reviewed by a doctor.
“Arrangements were in place to manage, store and administer medicines safely.” from the report
Activities and relationships
People took part in activities at home and in the community. The service also supported regular contact with relatives.
“People had the opportunity to take part in a range of activities that met their interests and needs.” from the report
Safeguarding procedure
needs fixingTwo staff needed prompting before explaining how to contact the local authority if management did not act on a concern. The manager said staff would be reminded.
“Two staff needed prompting before they told us that they would contact the host local authority if no action was taken by management.” from the report
Refresher training
needs fixingSome staff were behind with refresher training. Records showed they were completing the outstanding training at the time of inspection.
“The interim manager told us that he had recently completed an audit of staff training, which had identified that some staff were behind in completing some refresher training.” from the report
Staff supervision
minorSupervision meetings took place, but the records were inconsistent. The interim manager said the process would be reviewed.
“Staff supervision records varied in content and quality.” from the report
Condition of the home
minorThe premises showed wear and tear. Bathroom refurbishment and redecoration were planned.
“The premises were 'tired' looking and showed signs of wear and tear.” from the report
End of life records
needs fixingThe home was not providing end of life care at the inspection, but most records about people's end of life wishes were incomplete.
“However, these records were mostly not completed.” from the report
- 01Has a permanent manager now been appointed and registered with the CQC?
- 02Have all staff completed the refresher training that was outstanding at the inspection?
- 03What changes have been made to the staff supervision process?
- 04What refurbishment or redecoration has been completed, especially in the bathrooms and bedrooms?
- 05Have people's end of life wishes and preferences now been recorded with their involvement and that of their relatives?
This was an unannounced comprehensive inspection covering all five key questions and both the premises and the care provided. This explanation was written from the published report of 11 January 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.
What inspectors found, December 2016
Rated Good overall, but Safe remained Requires Improvement while inspectors checked improvements to how people's money was managed.
This was an unannounced focused inspection on 22 November 2016. It followed a comprehensive inspection in July 2016, when the home was found not to be managing people's money safely enough.
Inspectors checked financial records, support plans, receipts, cash balances and management checks. They found that the home had followed its action plan and was now meeting the legal requirements.
The home had stopped staff buying refreshments or other items with people's money. People's spending records were clearer, and there were systems to protect people from financial abuse.
The overall rating was Good. Safe was still rated Requires Improvement because inspectors wanted to see a longer period of consistently good practice before changing that rating. This inspection only looked at Safe.
Safer money handling
The home had improved its arrangements for storing and managing people's money. Inspectors found systems to protect people from financial abuse.
“People's monies were stored and managed safely. Systems were in place to protect people from financial abuse.” from the report
Clearer financial records
Inspectors found appropriate records of income and spending, with regular checks by care workers and the registered manager.
“Records showed that frequent checks of people's expenditure and cash balances were carried out by care workers and the registered manager.” from the report
Spending reflected people's choices
Purchases matched people's recorded preferences, including activities such as cinema visits and swimming.
“Records showed that purchases matched people's individual expenditure preferences which were recorded in their financial support plan” from the report
Safe rating not yet improved
needs fixingAlthough the immediate problems had been addressed, inspectors wanted a longer period of consistently good practice before changing the Safe rating.
“While improvements had been made we have not revised the rating for this key question; to improve the rating to 'Good' would require a longer term track record of consistent good practice.” from the report
Financial plans still being reviewed
minorThe manager was still working to add more detail and regular review arrangements to people's financial support plans.
“The registered manager told us that he planned to review each person's financial support plan to ensure they included more detail and guidance about each person's specific financial needs and to show they were regularly reviewed.” from the report
- 01Has the interim policy stopping staff from buying items with people's money now been replaced by an approved policy?
- 02How often are people's financial support plans reviewed?
- 03How are best-interest decisions recorded when someone cannot decide about a purchase?
- 04How often are people's cash balances and spending records checked, and who reviews those checks?
- 05What evidence will you use to show a longer period of consistently safe money management?
This was an unannounced focused inspection of Safe only, checking improvements after the earlier comprehensive inspection; it did not assess the other four questions. This explanation was written from the published report of 15 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 90 Capel Gardens
3 rated inspections over 2 years: the service has held its Good rating throughout.
- January 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Goodstayed GoodSafe: Requires improvement
- August 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- April 2011
Registered with the Care Quality Commission on 20 April 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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