CQC report explained · a residential care home
What the CQC found at Shining Star
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found medicines were managed safely, risks were assessed, there were enough staff and recruitment checks were robust. Infection control had improved since the previous inspection.
- Effective?
- Good
- People were supported with food, drink, health care and specialist dietary needs. Inspectors found DoLS applications and authorisations were up to date, and staff received training and supervision, although some training was outstanding.
- Caring?
- Good
- Staff respected people's privacy and dignity and encouraged independence. Relatives and advocates were able to contribute to decisions about care.
- Responsive?
- Good
- Care plans were personalised and communication needs were recorded. People could take part in activities they enjoyed, go out into the community and raise complaints.
- Well-led?
- Good
- Records and quality checks had improved and inspectors found an open, person-centred culture. There was a new manager applying to be registered with CQC.
What inspectors found, February 2022
Shining Star is Rated Good; inspectors found person-centred care and improvements since the previous inspection, with some staff training still outstanding.
The inspection was unannounced and took place on 17 December 2021. One inspector spoke with staff, a visiting professional and a relative, and reviewed care records, medicines records, staff files and management documents.
The home was supporting three people, all autistic or with learning disabilities, in a setting for up to four people. Inspectors rated all five areas Good. They found people were safe, treated with dignity, supported to make choices and helped to take part in activities and community life.
The home had improved since the previous inspection, when it was rated Requires Improvement and had several breaches of regulation. At this inspection, inspectors found the improvements were sufficient and the home was no longer in breach of regulations.
Some staff training was still outstanding, although the manager had shown how this would be completed. The home also did not have a manager registered with CQC, but a manager was applying to be registered.
Person-centred care
The home focused on people's individual choices, preferences and independence. Inspectors found that people were placed at the centre of care.
“Their model of care was person centred, placing people at the heart of the care.” from the report
Safe medicines
Medicines records were up to date and audits were being completed regularly. Staff had medicines training and competency checks.
“At this inspection all documentation was in order and up to date.” from the report
Respect and dignity
Staff knocked before entering bedrooms, protected privacy during personal care and encouraged people to do things for themselves.
“People's privacy and dignity was respected.” from the report
Activities and community life
People were supported to take part in activities they liked, including shopping, drives, arts and crafts, and visits to places of interest.
“People were able to participate in activities they liked to do.” from the report
Improved management
Records and quality checks were much better than at the previous inspection. Inspectors found the audits were available and in order.
“At this inspection the provider had made improvements. All paperwork we saw was up to date and quality assurance audits were accessible and in order.” from the report
Training still outstanding
minorSome staff training had not yet been completed. The manager had a plan to complete it, so ask to see whether this has now happened.
“The registered manager was able to show us how they were ensuring outstanding training was going to be completed.” from the report
Manager registration
minorThe home did not have a manager registered with CQC at the time of inspection. A manager was applying to be registered.
“There was a new manager at the service, and they were in the process of applying to be registered with CQC.” from the report
- 01Which staff training was still outstanding at the inspection, and has it now been completed?
- 02What is the current position of the manager's application to register with CQC?
- 03How are medicines audits checked regularly, and what happens if an error is found?
- 04How will you support my relative's communication needs, choices and preferred activities?
- 05How are DoLS authorisations and best-interest decisions kept up to date?
This was an unannounced planned inspection covering all five key questions, including infection prevention and control under Safe. This explanation was written from the published report of 26 February 2022 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, March 2021
Rated Requires Improvement; inspectors found unsafe medicines and record keeping, unlawful liberty restrictions, and gaps in infection and food safety.
This was a focused inspection on 28 January 2021. It followed the death of a person using the service through choking and looked mainly at Safe and Well-led. The inspector spoke with four staff members, reviewed care, medicine and management records, and received feedback from two relatives.
The home had detailed risk assessments and personalised care plans. Staff were trained, staffing levels were sufficient, and there were systems for safeguarding and learning from incidents. However, medicines records were out of date or poorly completed. Infection control checks missed gaps, temperatures were not always recorded during a COVID-19 outbreak, and some food was out of date or unlabelled.
People had been deprived of their liberty without the required legal authorisation. The provider applied for renewals once this was identified. Quality checks had not found several of these problems, so the overall rating fell from Good to Requires Improvement. No evidence of harm was found in the issues described.
Personalised care
Care plans described people's needs, preferences, routines and communication in detail. They gave staff practical guidance about how to support each person.
“Care plans were personalised and extensive, providing insight into people's lives, what was important to them and how staff should support them live as full and meaningful lives as possible.” from the report
Risk management
Inspectors found detailed risk assessments covering areas such as community activities, finances, night-time welfare and electrical appliances.
“At the time of inspection, people at the service were kept safe as the service assessed and monitored risks to them.” from the report
Staffing and training
There were enough staff, and staff completed training and competency checks for their roles. Recruitment checks were also completed.
“There were sufficient staff who were trained to provide person centred care.” from the report
Communication support
The home recorded how each person communicated and used pictorial menus to support choices.
“Care plans contained communication support plans and provided information about how individuals communicated.” from the report
Learning from incidents
Incidents and accidents were recorded, analysed and used to share learning with staff.
“Lessons were learned where things went wrong.” from the report
Medicine records and administration
seriousOne medicine file contained paperwork that was overdue for review. Medicine administration had also been written on the back of a record sheet, which could lead to errors.
“People's medicines were not always managed safely.” from the report
Unlawful liberty restrictions
seriousRequired applications and authorisations under Deprivation of Liberty Safeguards were out of date or had not been made. This meant people were deprived of their liberty without lawful authority.
“People's DoLS documentation was out of date.” from the report
Food storage
needs fixingSome food in the fridge was unlabelled and appeared out of date. Staff could not confirm whether it had recently been defrosted.
“We found some food stuff in the fridge which was not labelled.” from the report
Weak quality checks
needs fixingAudits did not identify the problems found with medicines, infection control, temperature records or other documentation. Some staff had not signed to confirm they had read care plans.
“The provider's oversight of such procedures was not sufficiently robust enough to ensure they knew when this happened.” from the report
- 01Have all medicine instructions and records been reviewed and corrected since the inspection?
- 02How do you now check that COVID-19 or other infection monitoring records are completed every day when required?
- 03Have current Deprivation of Liberty Safeguards applications and authorisations been obtained for everyone who needs them?
- 04How do you check that food in the fridge is labelled, dated and safe to use?
- 05How do you make sure every staff member has read and understood each person's care plan?
This was a focused inspection of Safe and Well-led, with specific parts of Effective and Responsive also considered; those two ratings were not reviewed and Caring was not rated. This explanation was written from the published report of 27 March 2021 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 Shining Star
5 rated inspections over 7 years: the service has held its Good rating throughout.
- February 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2021Requires improvementdown from GoodSafe: Requires improvementEffective: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Requires improvement
- December 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- October 2012
Registered with the Care Quality Commission on 19 October 2012.
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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