CQC report explained · a residential care home
What the CQC found at Safeharbour (254 Hagley Road)
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2019
Rated Good; inspectors found safe, kind and personalised care, with minor checks on staff DBS records and one medicines recording error.
This was an unannounced planned inspection on 09 May 2019. One inspector reviewed information about the home, spoke with relatives, the manager and staff, and checked care, recruitment and management records.
The home supported six people with learning disabilities. Inspectors rated all five areas Good. They found people were safe, received their medicines on time, and were supported by staff who understood their needs and communication.
The home had improved since the previous inspection, which was rated Requires Improvement and published on 09 May 2018. Medicines monitoring, best-interest decision records and quality checks had improved.
Personalised communication
Staff understood people's individual signals and used different methods to help them express choices and needs.
“Staff were able to explain people's individual signals, gestures and body language to anticipate their needs” from the report
Kind and respectful care
Staff knew people's histories and preferences, promoted dignity and supported people to become more independent.
“Staff spoke with kindness and compassion about the people they supported and told us they enjoyed their jobs.” from the report
Safe care and staffing
Risk assessments were regularly reviewed, staffing was based on people's needs, and staff understood safeguarding responsibilities.
“Staffing levels were set consistent with people's dependency needs to ensure that they were supported safely.” from the report
Improved medicines monitoring
A new electronic system had improved medicines monitoring and auditing since the previous inspection.
“This meant people received their medicines on time and in a safe way.” from the report
Meaningful activities
The home offered varied activities and looked for new experiences that matched people's interests and abilities.
“There was a strong emphasis on the provision of activities that were meaningful to the people living in the home.” from the report
DBS checks
needs fixingSome staff members had not had their DBS records reviewed for a few years. The manager agreed to discuss introducing checks at least every three years.
“This was because some staff members had not had their DBS reviewed for a few years.” from the report
One medicines recording error
minorRecords were generally accurate, but inspectors found one recording error. They said the error would have been identified at the next stock balance check.
“Records were accurately completed, although there was one recording error however, this would have been identified at the next stock balance check.” from the report
- 01How often are staff DBS records checked now, and what happens if a check is overdue?
- 02What checks are made each day to prevent and identify medicines recording errors?
- 03How will you make sure care plans and risk assessments stay up to date when a person's needs or behaviour changes?
- 04How are people involved in choosing their activities and making everyday decisions if they cannot communicate verbally?
- 05How will you continue the improvements made since the previous inspection?
This was an unannounced planned inspection of the care home, including the premises and care provided, and it assessed all five CQC questions. This explanation was written from the published report of 14 June 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, May 2018
Rated Requires Improvement; inspectors found kind, personalised care but serious weaknesses in medicines and quality checks.
This was an unannounced inspection on 12 March 2018. Inspectors looked at the building, care and support, medicines, staff recruitment and training, records, incidents and quality checks. They spoke with one person, two relatives, four staff members, the registered manager and a visiting professional.
People were treated kindly and received care that reflected their needs and preferences. Staff supported people's privacy, dignity, independence, relationships, communication, meals, health needs and activities. People and relatives said they felt safe and knew how to raise concerns.
The main problems were medicines management, recording best-interest decisions and checks on the quality and safety of the service. Some medicines were out of date, records did not always match the instructions, and staff medicine skills had not been checked every year. The overall rating was Requires Improvement. Safe, Effective and Well-led were Requires Improvement, while Caring and Responsive were Good.
Personalised support
Care plans described people's physical, health and behaviour support needs. Staff used handovers and regular reviews to respond to changes.
“Plans to guide staff in supporting people were detailed and up to date.” from the report
People felt safe
People and relatives said they felt safe. Staff understood how to recognise abuse and how to report concerns.
“I have peace of mind knowing [person's name] is living there.” from the report
Activities and family contact
People were offered activities, holidays and ways to maintain important relationships. Easy-read timetables and pictorial information helped people make choices.
“People were encouraged to maintain their relationships with family and friends” from the report
Medicines were not managed safely
seriousInspectors found out-of-date medicines, faded instructions, inaccurate stock records and unclear PRN protocols. Medicine storage temperatures were not always recorded, and staff medicine administration skills had not been checked every year.
“The provider and staff practices of managing people's medicines, was not safe.” from the report
Quality checks missed problems
seriousAudits did not identify important shortfalls in medicines, complaints or best-interest records. The provider could not show evidence of a scheduled monthly audit in January 2018.
“The provider had not taken steps to ensure the systems used to monitor and check the quality and safety of services provided were consistently effective and supported improvements.” from the report
Best-interest decisions were not always recorded
needs fixingSome decisions made for people who could not make them themselves were not recorded. Relatives or advocates had not always been involved in the decision-making process.
“Not all best interest decisions taken had been recorded for example, three people had listening devices in use for their safety, but no best interest meetings/decisions had been recorded.” from the report
Communication training was incomplete
needs fixingSome people used Makaton, but not all staff had been trained in it. The manager had requested further training.
“Although some people living at the home used Makaton as a form of communication, not all staff had been trained.” from the report
- 01What has been done to remove out-of-date medicines and make sure medicine labels and instructions are clear?
- 02How do you now check medicine stock, fridge temperatures and staff medicine administration skills?
- 03How are PRN medicines explained so staff know when they should be given?
- 04How do you record best-interest decisions and involve relatives or advocates?
- 05What changes have been made to quality audits so they identify and fix problems promptly?
This was an unannounced inspection covering all five CQC questions, prompted partly by concerns about risk management and safe care and treatment. This explanation was written from the published report of 9 May 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 Safeharbour (254 Hagley Road)
4 rated inspections over 4 years: the service has held its Good rating throughout.
- June 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Safeharbour (254 Hagley Road) →
- May 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Safeharbour (254 Hagley Road) →
- May 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2013
Report published without a new overall rating.
- January 2013
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 20 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Dudley
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,230 a week. 88 can care for a couple. 10 years' experience on average.
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
“Knowing Mum was in Corina's care made an enormous difference to us and we knew she was in safe hands.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.