CQC report explained · a residential care home
What the CQC found at Redbrick Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Some medicines were stored at incorrect temperatures, and expired medicines had not all been returned to the pharmacy. Falls analysis also needed to improve so patterns and themes could be identified.
- Effective?
- Good
- Staff had relevant training and people received support with nutrition, hydration and health needs. Improvements had been made to mental capacity assessments and deprivation of liberty applications.
- Caring?
- Good
- People and relatives described staff as kind and patient. Inspectors saw people treated with respect, with their dignity, privacy, choices and independence supported.
- Responsive?
- Good
- Care plans reflected people's routines, preferences and changing needs. People had activities and could use the home's facilities, although people and staff wanted more opportunities to go out.
- Well-led?
- Good
- Management and staff communication had improved, and people's views were sought. However, audits had not identified the medicines storage and falls analysis concerns found by inspectors.
What inspectors found, March 2019
Rated Good overall, but Safe Requires Improvement because medicines were not always stored safely and falls analysis needed to improve.
This was an unannounced inspection on 23 and 25 January 2019. Inspectors spoke with people, relatives and staff, observed care, checked records and medicines, and toured the home.
People and relatives generally said they felt safe and were happy with the care. Inspectors found kind and respectful staff, personalised care, good support with food and drinks, and access to health professionals.
The main problems were in medicines storage. Some medicines had been kept at unsafe temperatures, expired medicines had not all been returned, and the medicines trolley did not have enough space. Falls analysis also did not fully identify patterns that might help prevent further falls.
The overall rating was Good. Safe was rated Requires Improvement, while Effective, Caring, Responsive and Well-led were rated Good. This was better than the previous overall rating of Requires Improvement in the report published on 26 March 2018. No enforcement action was required.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff treating people with kindness, dignity and respect.
“People and their relatives described staff as kind and patient.” from the report
Personalised support
Care plans included people's histories, routines, preferences and risks. Staff adapted their approach to help people keep choice and control.
“Care plans included information about people's history, health, social needs and were person-centred.” from the report
Improved support and training
Staff had relevant training, supervision and handovers. Inspectors found improvements in moving and handling, nutrition monitoring and mental capacity practice since the previous inspection.
“These improvements have been made.” from the report
Clean environment
People were happy with the home's hygiene. Domestic staff followed cleaning schedules and staff used protective equipment appropriately.
“People were happy with the standards of hygiene.” from the report
Activities and facilities
People could take part in activities and use communal spaces including a cinema room, sensory room, library area and café.
“People had access to planned and spontaneous activities which were displayed to inform them.” from the report
Medicine storage
seriousSome medicines were kept in a fridge below the safe temperature range. Expired medicines had not all been returned, and the trolley did not have enough space to separate medicines safely.
“Medicines were not always stored safely.” from the report
Falls analysis
needs fixingFive people had fallen in the previous three months, but the home had not fully identified patterns or themes from these incidents. The manager said this analysis would be improved.
“Patterns and themes had not been fully captured.” from the report
Quality checks
needs fixingAudits were in place but did not identify the medicines storage and falls analysis problems found during the inspection.
“The audits did not identify the concerns we found such as the analysis of falls to identify themes or patterns where these were evident.” from the report
Leadership cover
minorThe registered manager also oversaw two other locations. Staff said they would benefit from full-time leadership at the home.
“Staff felt they would benefit from having full-time leadership in place.” from the report
- 01How are medicine fridge temperatures checked now, and what happens immediately if they are outside the safe range?
- 02How are expired medicines identified and returned to the pharmacy?
- 03Has another medicines trolley been provided, and how are medicines kept separate for each person?
- 04What new process is used to analyse falls and identify patterns or themes?
- 05What leadership cover is in place when the registered manager is working at the other two locations?
This was an unannounced planned inspection that looked at the premises, care and all five CQC questions, following the previous Requires Improvement rating. This explanation was written from the published report of 22 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.
What inspectors found, March 2018
Requires Improvement overall; inspectors found kind, responsive care, but safety, staff support and management needed improvement.
This was an unannounced inspection over three days. Inspectors spoke with people living in the home, relatives, staff and a visiting health professional. They also observed care and checked care plans, medicines, staff records, rotas, complaints and quality checks.
People were generally treated kindly and with respect. Staff supported people's dignity, independence and choices. People received personalised care and could raise concerns. Meals had improved, and people had access to health professionals and some activities.
The inspectors found important weaknesses. Risk monitoring was not always completed, including checks for pressure sores, night-time welfare and dehydration. Some staff training and supervision had been delayed. There had also been several manager changes, staffing problems and weak quality checks. The overall rating Requires Improvement means the home was not consistently meeting the expected standard, although inspectors found no evidence that anyone had been harmed by poor practice.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff respond calmly to distress, protect dignity and spend time with people.
“People told us that the staff were kind and caring.” from the report
Personalised support
Care plans included people's routines, preferences, history, religious needs and ways to maintain independence.
“Care records were person-centred and included details of people's daily routines, when they liked to get up or go to bed and what people liked to eat and drink.” from the report
Prompt responses
At the inspection, staff responded promptly when people needed help. Call buzzers were answered without delay.
“We did not see any delays in responding to people; buzzers were answered promptly and staff spent time chatting with people.” from the report
Medicines training
Staff giving medicines had completed medicines training and a competency check. Inspectors observed safe checking and explanations before medicines were given.
“We found all staff who administered medicines had completed safe medicine training and a competency assessment had been carried out to ensure their practice was safe.” from the report
Access to health support
People were referred to health professionals when their needs changed, and staff followed recommendations.
“We saw from people's care records that they were referred to health professionals where their needs had changed.” from the report
Missed risk checks
seriousMonitoring for pressure sores and night-time welfare was not always completed as required. This could have left people without the planned protection from harm.
“A person at risk of developing pressure sores had not been supported to change their position at the recommended two hourly intervals.” from the report
Incomplete fluid records
needs fixingRecords did not consistently show how much some people at risk of dehydration had drunk. The manager said a daily checking system would be introduced.
“For three people we saw their records over the previous weeks had not been completed in full to show what amounts they had managed to drink.” from the report
Training and supervision gaps
needs fixingSome staff had not completed all required training, and most had not received planned supervision. A programme had been arranged to address this.
“As a result we saw some staff had not had all the required training and most staff had not had planned supervision to support them in their practice.” from the report
Unstable management
needs fixingThere had been three manager changes since the home opened, and there was no registered manager or full management team at the inspection. This affected staffing, training and consistency.
“There had been three changes of manager since the home began operating in September 2017.” from the report
Quality checks missed problems
needs fixingAudits covered areas such as medicines, accidents and the environment, but did not identify the gaps in risk monitoring found by inspectors.
“However we identified these needed further improvement as the provider's audits did not identify the shortfalls we found during the inspection.” from the report
Activities not fully developed
minorPeople had some activities and social contact, but staffing levels had limited the use of the library, garden room and sensory room. Plans were in place to organise more activities.
“Whilst the facilities available included a library, garden room and sensory room these had not yet been fully utilised” from the report
- 01How do you now check that people at risk of pressure sores are repositioned at the required intervals?
- 02How are fluid records checked each day for people at risk of dehydration?
- 03What training and supervision has each member of staff completed since this inspection?
- 04Who is currently responsible for management when the manager is absent, and has a full management team been appointed?
- 05How do your audits now identify falls, missed care checks and other risks before they affect people?
This was an unannounced first inspection covering the overall service and all five CQC questions, including the premises and care provided. This explanation was written from the published report of 28 March 2018 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 Redbrick Court
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- March 2019Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2017
Registered with the Care Quality Commission on 7 July 2017.
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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