CQC report explained · a residential care home
What the CQC found at 35 Hawthorn Road
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found problems with medicine storage and record checks. They could not confirm that some medicines had been administered safely, although staffing, safeguarding, infection control and emergency procedures were positive.
- Effective?
- Good
- Staff were trained and supported, consent was sought in line with the Mental Capacity Act, and people received support with food, drink and healthcare.
- Caring?
- Good
- People were treated with respect and patience. Staff knew people well and used individual communication methods to support choice and independence.
- Responsive?
- Good
- Care plans were personalised and regularly reviewed. Information was provided in accessible formats, and activities reflected people's preferences.
- Well-led?
- Requires improvement
- Management was inconsistent while the registered manager was absent. Inspectors also found that medication audits and the process for acting on external audit findings were not clear.
What inspectors found, April 2019
Rated Requires Improvement; inspectors found kind, personalised care but unsafe medicine processes and inconsistent management.
This was a planned comprehensive inspection on 13 March 2019. One inspector visited the home, spoke with staff, relatives and managers, and checked care records, recruitment files and management records.
The home provided accommodation and personal care for up to six people with hearing, vision and other sensory disabilities. Inspectors found people were treated with respect, supported to make choices and given care that reflected their individual communication needs.
However, some medicine arrangements were unsafe. There were no running total checks for some medicines and no available medication audits. The home was also not managed consistently, partly because the deputy manager was sometimes working as care staff while managing the home.
The overall rating was Requires Improvement. Safe and well-led were rated Requires Improvement, while effective, caring and responsive were rated Good. The home was rated Good at the previous inspection in January 2016.
Kind relationships
Inspectors saw that people were comfortable with staff. Relatives said staff treated people very well.
“People were comfortable in the presence of the staff and it was obvious that the staff knew the people well.” from the report
Personal communication
The home used individual communication methods, including tactile cards and hand signs, to help people express choices.
“People's support plans detailed how to specifically communicate with each person and we observed this in practice during inspection.” from the report
Personalised care
Care plans included people's preferences, routines, needs and communication requirements. They were reviewed regularly.
“Care records indicated that the care and support people received was tailored around their wishes, needs and preferences.” from the report
Learning from incidents
The provider monitored accidents and incidents and made changes after problems, including an incident involving a person making a hot drink.
“The manager and provider acted to ensure lessons were learnt from any incidents.” from the report
Medicine checks
seriousSome medicine arrangements were unsafe. The home could not show running total checks for as-needed medicines or medication audits confirming who checked administration.
“We were unable to check 'as and when' (PRN) medication as there were no running total checks.” from the report
Medicine storage
seriousThe locked medication cabinet was not fixed or kept in a secure room. Medicines requiring refrigeration were stored in a household fridge with food.
“This meant it could be removed by unauthorised persons.” from the report
Inconsistent management
needs fixingThe registered manager was absent and the deputy manager sometimes worked as support staff, making it difficult to carry out the management role consistently. Relatives and staff raised concerns about this.
“The deputy manager was also at times working as support staff and so not able to fulfil a management role.” from the report
Unclear follow-up records
needs fixingInspectors could not see clear documented evidence showing what actions followed a water-supply risk assessment, who was responsible and when actions were completed.
“There was no process in place to evidence what actions had been taken, who had responsibility and dates these actions were carried out.” from the report
- 01What changes have been made to secure the medication cabinet and medicines kept in the fridge?
- 02How do you now record running totals for as-needed medicines and check that medicines have been given correctly?
- 03Who is responsible for managing the home when the registered manager is absent, and how will consistent management be maintained?
- 04What evidence is now kept to show that actions from water-supply and other external audits have been completed?
- 05How will the home continue to support each person's individual communication method, choices and independence?
This was a planned comprehensive inspection covering all five CQC questions; the previous inspection in January 2016 rated the home Good. This explanation was written from the published report of 26 April 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.
Every inspection of 35 Hawthorn Road
2 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- April 2019Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- April 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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