CQC report explained · a residential care home
What the CQC found at SENSE The Old Coach House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Relatives felt people were safe, and staff understood safeguarding and individual risks. Medicines, staffing and recruitment were found to be safe, although some environmental risks and incomplete safety-check records were identified.
- Effective?
- Good
- Staff knew people's needs and had received induction, training and supervision. People were supported with food, drink, healthcare, consent and independence.
- Caring?
- Good
- Relatives described staff as kind, friendly and respectful. People were supported with dignity, privacy, personal choices and independence.
- Responsive?
- Good
- Care plans recorded people's likes, dislikes and communication needs. People were supported to go out, take part in activities, maintain relationships and raise complaints.
- Well-led?
- Requires improvement
- Relatives and staff spoke positively about the management, and the registered manager understood their legal responsibilities. However, quality checks had not identified several safety and record-keeping shortfalls.
What inspectors found, February 2020
Rated Good overall; inspectors found safe, kind and responsive care, but management checks needed improvement.
This was an unannounced inspection on 22 January 2020. The inspector spoke with all five people living at the home, two relatives, five staff and the registered manager. They also reviewed care, medicines, staffing and management records, and looked around the building.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found enough trained staff, safe medicine arrangements, personalised support and kind care. People were supported to make choices, stay independent, eat and drink well, access healthcare and take part in activities.
Well-led was rated Requires Improvement. Some safety and record-keeping problems had not been found by the home's own checks. These included missed records of twice-daily checks, a fire door that could not close properly, possible injury risks from fixtures and a toilet needing repair.
The overall rating stayed Good, and the previous overall rating was also Good. The report says the home would continue to be monitored until the next planned inspection.
Kind and respectful care
Relatives said staff were caring and considerate. Inspectors saw people treated with respect and supported to keep their independence.
“The staff are so caring and considerate. They brought them [person's name] to a family funeral.” from the report
Activities and community life
People were supported to go out, enjoy activities and follow their interests, including holidays and community visits.
“Two people went out with staff to a scheduled activity during the morning.” from the report
Staffing and training
There were enough staff to meet people's needs, and recruitment checks were completed before staff started work. Training and supervision records were in place.
“Completed recruitment checks on staff prior to them commencing in post ensured staff were safe to work with people.” from the report
Missed safety-check records
needs fixingA support plan required twice-daily checks of specific items for one person, but records did not show that these checks happened every day.
“Records did not confirm these checks had been undertaken twice every day.” from the report
Fire door obstruction
seriousA laundry fire door was propped open with an ironing board. Inspectors said it might not close properly if there were a fire.
“This meant if a fire were to occur the door could not close as it should to prevent flame and smoke spread.” from the report
Possible injury risks
needs fixingA suitcase was stored on top of a wardrobe, and some radiator covers were loose. Inspectors said these could cause injury if they fell or were not repaired.
“There was a potential risk the suitcase could fall and cause injury.” from the report
Toilet maintenance
needs fixingA toilet had a rusty, peeling radiator and damaged boarding under the sink. Inspectors said these surfaces could harbour bacteria.
“This meant there was a risk that those surfaces could harbour bacteria.” from the report
- 01Have the twice-daily checks identified in the report been completed consistently, and how are they now recorded?
- 02Was the laundry fire door repaired or cleared so it can close properly?
- 03Have the suitcase, loose radiator covers and damaged toilet surfaces been made safe?
- 04How has the home improved its audits so that safety and record-keeping problems are found sooner?
- 05How many staff vacancies remain, and how is staffing cover arranged when someone is absent?
This was an unannounced inspection of the care home, covering all five quality questions, the care provided and the premises. This explanation was written from the published report of 22 February 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, September 2017
Rated Good; inspectors found safe, kind and personalised care, with some records and staff competency checks needing improvement.
This was an unannounced comprehensive inspection over two visits. Inspectors observed care, spoke with relatives and staff, and checked care plans, medicines, recruitment records and quality checks.
The home supported five people with learning disabilities and sensory impairments. Inspectors found enough staff, safe medicines arrangements, suitable risk assessments and staff who understood people's needs. People were treated with kindness, dignity and respect, and were supported with activities, health care, independence and family relationships.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. This was the same overall rating as at the previous inspection in September 2015.
Safe support
Staff understood people's risks and knew what to do if abuse or other safety concerns arose. Inspectors saw people being supported safely while retaining as much independence as possible.
“We saw people received safe care that wherever possible promoted their independence.” from the report
Kind and respectful care
Staff knew people well and used their communication methods, including gestures, sounds and objects of reference. People's privacy, dignity and independence were respected.
“We observed many kind, caring interactions between people and staff throughout the inspection.” from the report
Personalised activities and relationships
Activities were provided each day and matched people's interests and needs. The home also supported contact with family members and other important people.
“People had access to activities on a daily basis and these were kept under review to make sure people enjoyed them.” from the report
Good leadership and checking
Relatives and staff described the manager as approachable. The provider and manager used audits and checks to monitor safety and quality.
“The registered manager and the registered provider had developed and utilised a wide range of audits and checks” from the report
Accident and incident records
needs fixingInspectors said the records did not always contain enough detail to identify patterns in injuries or incidents.
“Some improvement was needed to the detail of the records to ensure any patterns would be identified.” from the report
Staff vacancies
needs fixingCasual and agency staff use had recently increased because of vacancies. The report says these staff were known to people and recruitment was in progress.
“Recently the use of casual and agency staff had increased to cover staff vacancies.” from the report
Competency checks
needs fixingA new system for checking staff skills had started, but inspectors found that not all areas of practice had yet been assessed.
“The provider had recently developed a system to check staff competency to make sure staff had the right skills to support people and this had been implemented but not all areas of practice had been assessed.” from the report
- 01What has been done to improve the detail recorded after accidents and incidents, and how are patterns now reviewed?
- 02Have the staff vacancies been filled, and how often are casual or agency staff currently used?
- 03Have all staff competency checks now been completed, including the areas not assessed at the inspection?
- 04How will you make sure new or temporary staff understand each person's communication methods, risks and preferences?
- 05How are activities and family contact reviewed to make sure they still match each person's wishes?
This was an unannounced comprehensive inspection covering all five key questions, with a second visit to meet people who were away on the first day. This explanation was written from the published report of 22 September 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 SENSE The Old Coach House
3 rated inspections over 4 years: the service has held its Good rating throughout.
- February 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- May 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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