CQC report explained · a residential care home
What the CQC found at 20-32 Horton Street
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Risk assessments had been improved, medicines were managed safely, hygiene systems were in place and staffing levels met people's needs.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Well-led?
- Good
- The home had a registered manager and effective systems for checking quality and safety. Identified issues were acted on in a timely way.
What inspectors found, January 2019
Rated Good; inspectors found that earlier safety and management problems had been addressed, although improvements still needed to be sustained.
This was an unannounced focused inspection on 9 January 2019. It checked whether the home had made improvements after the previous inspection on 19 September 2018.
Inspectors looked at Safe and Well-led. They found that risks were assessed and managed, safeguarding concerns were reported, medicines were given as prescribed, and there were enough staff. They also found that audits and checks were now effective.
The home was rated Good overall. At the previous inspection it was rated Requires Improvement and had breached Regulations 13 and 17. Inspectors found that these legal requirements had been met at this inspection.
Risks were managed
Risk assessments and care plans were reviewed and monitored. Staff could explain how they supported people with specific risks.
“People were protected from risks associated with their health and care needs because risk assessments and associated care plans were developed, reviewed and monitored.” from the report
Enough staff
Inspectors found enough staff to meet people's needs. Agency use had reduced, supporting more consistent care.
“We saw that people were supported by sufficient numbers of staff.” from the report
Stronger quality checks
The home had introduced additional audits and improved existing ones. Inspectors found that issues identified were dealt with promptly.
“We saw that these were now more robust and we could see that issues identified were being actioned in a timely way.” from the report
Improvements need to last
minorThe manager recognised that the improvements needed to continue and develop. Families may want to check how this is monitored now.
“They recognised that whilst improvement had been made these needed to be sustained and built on.” from the report
Some environmental work remained
minorFurther work was still planned with the landlords, including work on the ventilation system.
“There was also work taking place with the landlords of the home to improve some of the environmental issues, for example the ventilation system.” from the report
- 01How do you check that improvements to incident reporting and safeguarding have been maintained?
- 02How are risk assessments reviewed after an incident to reduce the chance of it happening again?
- 03What progress has been made with the ventilation and other environmental work?
- 04How do you make sure staffing levels remain flexible enough for appointments and activities?
- 05How does the communication system keep relatives informed about the person’s care and wellbeing?
This was an unannounced focused inspection of Safe and Well-led only; the other three key question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 31 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, November 2018
SENSE - 20-32 Horton Street was rated Requires Improvement; inspectors found kind, responsive care but serious weaknesses in safeguarding and quality checks.
Inspectors made an unannounced comprehensive inspection visit on 19 and 24 September 2018. They met all six people living at the home, observed care, spoke with staff and relatives, and checked care, medicine, incident and management records.
The home was rated Good for Effective, Caring and Responsive. Staff knew people well, treated them with kindness and respect, supported their health and communication needs, and helped them take part in activities and maintain relationships.
Safe and Well-led were rated Requires Improvement. Some injuries and incidents were not properly investigated or reported. Risk assessments and safety problems identified by audits were not always dealt with promptly. The home was in breach of Regulations 13 and 17, and CQC issued a warning notice for Regulation 17.
Activities and independence
People were supported to take part in activities linked to their interests, use the local community and develop their independence.
“People had the opportunity to engage in activities that were based on their interests and meaningful to them.” from the report
Staffing and recruitment
Inspectors found enough staff to meet people's needs during the inspection, and recruitment checks had been completed.
“People were supported by enough members of staff, who had been safely recruited, to ensure that they were kept safe and their needs were met.” from the report
Medication support
Inspectors saw medicines being given as prescribed, with guidance available about people's medicines and how they preferred to take them.
“We saw that medication was given to people as prescribed.” from the report
Safeguarding and unexplained injuries
seriousSome incidents, injuries and bruises were not recognised as safeguarding concerns, fully investigated or reported to the appropriate organisations. This included altercations during transport and injuries with unclear causes.
“Incidents that had occurred in the home had not always been recognised as a safeguarding incident and had not been reported to the local safeguarding teams, police and CQC.” from the report
Unsafe furnishings not dealt with
seriousAn audit had identified failed mattresses, including one with ripped sponge, but action had not been taken before the inspection. A dining chair also had exposed foam.
“One person's mattress audit stated that the sponge inside the mattress was ripped and there was associated risks to the person in relation to this.” from the report
Weak quality monitoring
seriousThe home's audits did not consistently lead to action. Problems were repeated or left unresolved, including environmental risks, incident records and risk assessments.
“Systems and processes in place to assess and monitor the safety and quality of the service had not been effective at ensuring the required improvements were made in a timely way.” from the report
- 01How are safeguarding incidents, altercations and unexplained injuries now identified, investigated and reported?
- 02What checks confirm that mattresses, furniture and other equipment are safe, and how quickly are problems repaired or replaced?
- 03How do you make sure risk assessments and support plans are reviewed after an incident or change in need?
- 04What action was taken after the medicine doses were missed, and how do you now prevent and monitor missed doses?
- 05What evidence can you show that the quality monitoring improvements required by the warning notice have been completed and maintained?
This was an unannounced comprehensive inspection covering all five key questions, with the report comparing the results with the previous inspection in February 2016. This explanation was written from the published report of 21 November 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 20-32 Horton Street
3 rated inspections over 3 years: the service has held its Good rating throughout.
- January 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2018Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- March 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- March 2012
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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