CQC report explained · a residential care home
What the CQC found at Sitwell Grove
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and managed while people retained as much independence as possible. Medicines, staffing, safeguarding, fire safety and infection control were also found to be managed safely.
- Effective?
- Good
- People's needs and preferences were assessed and reflected in care plans. Staff had relevant training, people chose their food and drink, and they were supported to access healthcare.
- Caring?
- Good
- People were treated with dignity, kindness and respect. They were involved in decisions, supported to communicate and encouraged to develop skills and independence.
- Responsive?
- Good
- Care plans were personalised and regularly reviewed. People were supported with communication, relationships, hobbies, education, community activities and complaints.
- Well-led?
- Good
- Inspectors found approachable management, good communication and effective quality checks. The managers used feedback and partnership working to improve care.
What inspectors found, November 2019
Sitwell Grove rated Good; inspectors found safe, kind and personalised care, with written learning from incidents still needing improvement.
This was an unannounced planned inspection on 10 October 2019. One inspector spoke with three people, relatives, staff and professionals, observed care and reviewed care, staff training and quality records.
The home supported four people with learning disabilities. Inspectors found that people were safe, treated with kindness and involved in decisions about their care. Staff understood people's individual needs and supported choice, independence, activities and contact with relatives.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. This means the inspectors found consistently good care and management, but it does not mean every part of the service was perfect.
The overall rating remained Good, unchanged from the previous inspection published in July 2017. Inspectors noted that there was no written action plan showing what had been done after analysing incidents, and that end of life wishes needed further discussion at the right time.
Personalised support
People were involved in planning their care and were supported according to their individual needs, choices and preferences.
“People using the service received planned and coordinated person-centred support that was appropriate and inclusive for them.” from the report
Choice and independence
People were encouraged to make decisions, learn skills and do more for themselves, including cooking, shopping and household tasks.
“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
Kind and knowledgeable staff
Relatives and professionals said staff understood people's needs and provided caring, personalised support.
“People's relatives told us that people were cared for by competent staff who were kind, understood each person's individual needs and provided people with personalised care and support.” from the report
Safe medicines practice
Medicines were handled safely, and positive behaviour strategies meant nobody was prescribed certain medicines to calm behaviour at the time of inspection.
“This had led to no one being prescribed these types of medicines.” from the report
Activities and relationships
People were supported to keep in touch with family and friends and to take part in activities suited to their interests.
“People took part in a range of activities that met their preferences and personal interests.” from the report
Incident learning was not fully recorded
needs fixingManagers reviewed incidents and took action, but they had not written an action plan to record the response to the analysis. The deputy manager said this would be documented in future.
“However, there was no written action plan from the analysis of incidents.” from the report
End of life wishes need further discussion
minorSome information was recorded about people's wishes, but the managers recognised that these wishes needed to be discussed further at the appropriate time.
“The registered manager and deputy manager were aware that people's end of life wishes was an area to be discussed further with people at the right time.” from the report
- 01How do you now record the actions taken after reviewing accidents and incidents?
- 02How will you discuss and update my relative's end of life wishes?
- 03How will my relative be involved in planning and reviewing their care plan?
- 04What activities and opportunities for independence would be available for my relative?
- 05How would you support my relative's communication needs and preferences?
This was an unannounced inspection covering all five key questions and the care home premises and care; the supported living part of the registration was not receiving personal care at the time. This explanation was written from the published report of 22 November 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, July 2017
Sitwell Grove was rated Good; inspectors found kind, personalised care, with a few minor issues in medicines, cleanliness and the building.
This was an unannounced comprehensive inspection on 13 June 2017. One inspector spoke with all four people living there, staff and relatives, and checked care records, staff records, audits and policies.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people felt safe, staff understood their needs, medicines were generally managed safely, and people were supported to make choices and stay involved in their community.
Inspectors identified some issues for the home to address. These included missing written instructions for some when-required medicines, laxatives not being kept in a medicine cabinet, dusty areas and cobwebs, a broken bathroom tile, and a lone-working policy that needed updating.
The home was still rated Good, as it had been at the previous inspection. The report says the provider was meeting its registration conditions and had suitable systems to monitor and improve the service.
Kind and respectful staff
People and relatives described staff as kind and said they listened. Inspectors saw friendly and respectful interactions.
“People told us that staff were kind and treated them well.” from the report
Personalised care
Care plans included people's preferences, goals, abilities and support needs. Staff knew people well and adjusted support when their needs changed.
“The three care plans we looked at were person centred in containing detailed information about a range of areas to do with people's lives and needs” from the report
Trained and supported staff
Staff had completed training relevant to their roles and to people's specialist needs. Records showed regular supervision and appraisals.
“Staff received the training they needed to carry out their roles and responsibilities” from the report
Good management checks
The home used audits, feedback, meetings and monitoring checks to review its quality and safety.
“Effective quality assurance systems to monitor and evaluate the quality of the service were in place.” from the report
Written instructions for medicines
needs fixingThere were no written protocols explaining when some when-required medicines should be given. Management said staff were expected to contact the manager first and that this would be documented.
“There were not protocols detailing the circumstances when the PRN medicines should be administered.” from the report
Medicine storage
needs fixingA box of laxative sachets was in a locked room but not inside a medicine cabinet. Management said it would be stored more securely.
“A box of laxative sachets, although stored in a locked room were not stored in a medicine cabinet.” from the report
Cleanliness and repairs
minorThe home was generally clean, but inspectors found dusty areas and cobwebs. A large broken bathroom tile also needed replacing.
“The home was generally clean, although there were areas which were dusty such as information documents displayed on the kitchen wall, and some cobwebs were noted in one area.” from the report
Lone-working policy
minorThe home had a lone-working policy, but management said it needed to be made more specific to the home's needs.
“The registered manager and deputy manager told us they would develop this policy so it related better to the specific needs of the home.” from the report
- 01What written instructions are now in place for when-required medicines, and how are staff checked on this?
- 02Are all medicines, including laxatives, now stored in the correct locked medicine cabinet?
- 03Has the broken bathroom tile been replaced, and how are cleanliness checks recorded?
- 04Has the lone-working policy been updated to reflect this home's specific risks and arrangements?
- 05How are staffing levels adjusted when people's needs change or they attend activities and appointments?
This was an unannounced comprehensive inspection covering all five CQC questions and the overall rating. This explanation was written from the published report of 18 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 Sitwell Grove
3 rated inspections over 4 years: the service has held its Good rating throughout.
- November 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 8 February 2011.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Harrow
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,330 a week. 81 can care for a couple. 12 years' experience on average.
“She handled the new situation in front of her with such professionalism and I felt I could trust her 100%.”
“I can truly say that Peter always put Dad at the centre of everything and I know that they found a great friendship in difficult times.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.