CQC report explained · a residential care home
What the CQC found at 115 Gough Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe medicines arrangements, appropriate risk assessments and good infection control. They noted a build-up of discarded furniture, fittings and garden waste in external areas, which the manager said they planned to remove.
- Effective?
- Good
- People had detailed assessments and care plans, and staff had relevant training and experience. Staff supported eating, drinking, health care, communication and independence, and worked with specialist professionals.
- Caring?
- Good
- Staff treated people with respect and kindness. They used individual communication methods to understand people's views and supported privacy, dignity and independence.
- Responsive?
- Good
- Care was personalised and updated when people's choices changed. People were supported with communication, family relationships, community activities and complaints.
- Well-led?
- Good
- The home had clear leadership, regular checks and a positive, person-centred culture. Families, staff and other people involved in care were asked for feedback, and the manager recorded actions taken to improve the service.
What inspectors found, January 2020
SENSE - 115 Gough Road was rated Good in all five areas; inspectors found safe, kind and personalised care.
This was an unannounced inspection on 28 November 2019. One inspector observed how people were supported, spoke with the registered manager and five support staff, reviewed care, medicines, staffing and management records, and spoke with a professional involved with the home.
The home supported five people with sensory impairments. Inspectors found enough staff, safe medicines systems, suitable training and a clean environment. Staff understood people's communication methods and supported choice, independence, health care, family relationships and a wide range of activities.
People were treated with kindness, dignity and respect. Care plans reflected people's preferences, and the home used meetings, audits and feedback to improve care. The overall rating and each of the five areas remained Good, the same as at the previous inspection published in July 2017.
Enough staff
Inspectors found sufficient staff on each shift, despite two vacancies. There was an established team, with many staff having worked at the home for more than five years.
“There were sufficient staff on each shift to meet the needs of people living in the service.” from the report
Skilled communication
Staff understood how each person communicated through gestures, vocalisations, sign language, objects and pictures. This helped people express their choices and needs.
“Staff were very observant and skilled in interpreting gestures and vocalisations used by people who lived in the service to communicate their wants and needs.” from the report
Choice and independence
People were supported to make choices, learn skills and do as much as possible for themselves, both at home and in the community.
“People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.” from the report
Activities and relationships
The home supported a wide range of activities, including walking, boating and climbing. Records also showed support for family relationships and community involvement.
“The provider supported the development and maintenance of relationships through an extensive activity programme in the community.” from the report
Person-centred leadership
The manager promoted a positive culture and used audits, meetings and feedback to monitor and improve care.
“The registered manager promoted a positive culture where they supported and empowered the staff team to be able to deliver person-centred care.” from the report
Outdoor areas needed clearing
minorInspectors saw discarded furniture, fittings and garden waste outside the home. The manager said this had been identified and would be removed in the following weeks.
“We saw external areas of the home where there was a build-up of discarded furniture, fittings and garden waste.” from the report
- 01Has the discarded furniture, fittings and garden waste seen outside the home been removed?
- 02How will you learn and interpret my relative's individual communication methods?
- 03How will you support my relative to make choices and become more independent?
- 04Which activities are currently available, and how do you match them to each person's interests?
- 05How will my family member's views and our feedback be included in reviews of their care?
This was an unannounced, planned inspection covering all five CQC questions; the overall rating and each question rating were reviewed. This explanation was written from the published report of 15 January 2020 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, July 2017
Rated Good; inspectors found safe, kind and personalised care, with some monitoring and confidentiality improvements needed.
This was an unannounced inspection on 16 June 2017. One inspector visited the home, met all five residents and observed care in communal areas. As residents could not speak with the inspector, observations were used to understand their experience. The inspector also spoke with managers, four staff and three relatives, and checked care plans, medicines, recruitment, training, incident and quality records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough suitably checked staff, safe medicines support, staff who understood residents' communication and care needs, and regular activities based on residents' interests.
There were some areas to improve. Checks did not identify three minor medicines issues, one person's significant weight loss, or all restrictions that needed authorisation. Some information about changes to care was not shared confidentially. The report says managers took or planned action in response.
Staff knew residents well
The established staff team understood residents' communication styles and care preferences. Inspectors saw staff respond to residents and provide reassurance when needed.
“People were supported by staff who knew them well.” from the report
Personalised communication and choice
Staff used different communication tools for each resident and supported people to make choices about care, meals, activities and where they spent time.
“We observed people being offered choices in all aspects of their care including at meal times, with activities and through where people wanted to spend their time.” from the report
Activities and community life
Residents had daily activities based on their interests, including opportunities for new experiences and involvement in the local community.
“People had a full and active life which was enhanced by their opportunity to access activities on a daily basis” from the report
Safe staffing and medicines support
Inspectors found enough staff, recruitment checks and medicines training. Medicines were stored safely and systems were in place for administration.
“People received safe support with their medicines from staff who had received training to provide this support.” from the report
Positive family feedback
Relatives said they were happy with the care and felt able to raise concerns. They also described the leadership positively.
“Relatives were happy with how the home was managed and staff felt supported in their roles.” from the report
Restrictions needed better checking
needs fixingAll residents had restrictions on their care. Applications for authorisation had been made, but the systems for checking whether restrictions were authorised needed improvement.
“Whilst people were being supported in the least restrictive way we noted that improvements were needed in the systems for checking whether the restrictions on people's care had been authorised.” from the report
Health monitoring missed weight loss
needs fixingThe home's monitoring systems did not identify that one resident had lost a large amount of weight over a short period. The report says this was acted on after the inspection and healthcare professionals were consulted.
“We noted that systems in place for monitoring people's health had not identified that one person had lost a large amount of weight in a short space of time.” from the report
Some medicines checks were not effective
minorInspectors found three minor medicines issues. The deputy manager investigated them and said action would be taken, but audits had not identified the improvements needed.
“The deputy manager took steps to investigate three minor issues we brought to their attention and informed us of action that would be taken to ensure this did not occur again.” from the report
Information was not always confidential
needs fixingSome information about changes to residents' care was shared in a way that was not confidential. The deputy manager said steps would be taken to prevent this happening again.
“We saw that some of this information was not shared confidentially.” from the report
- 01How do you now check that every restriction on a resident's care has the correct authorisation?
- 02What changes were made after the inspection to monitor weight loss and other changes in residents' health?
- 03What was changed after the three minor medicines issues, and how are medicines audits now checked?
- 04How do you make sure information about changes to care is shared confidentially?
- 05How are residents and their families involved in reviewing care plans and choosing activities?
This was an unannounced inspection covering all five CQC questions; the home had previously been rated Good in all areas at the October 2014 inspection. This explanation was written from the published report of 21 July 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.
Every inspection of 115 Gough Road
3 rated inspections over 5 years: the service has held its Good rating throughout.
- January 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 29 November 2010.
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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