CQC report explained · a residential care home
What the CQC found at Somerville House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found suitable risk assessments, safe medicines systems, infection control, recruitment checks and enough staff. They also found that safeguarding and accident-reporting processes were understood.
- Effective?
- Good
- This key question was not inspected during this focused visit.
- Caring?
- Good
- This key question was not inspected during this focused visit.
- Responsive?
- Good
- This key question was not inspected during this focused visit.
- Well-led?
- Good
- Inspectors found a positive, open culture and managers who responded to feedback. They noted that some management systems could still be made more robust.
What inspectors found, February 2023
Rated Good; inspectors found safe, kind and well-led care, with improvements since the previous Requires Improvement rating.
This was an unannounced focused inspection on 24 January 2023. Inspectors checked Safe and Well-led, spoke with people, relatives, staff and a health professional, and reviewed care, medicines, recruitment and management records.
Inspectors found that people were protected from avoidable harm. Risks were assessed, medicines were managed safely, infection control and cleanliness had improved, and there were enough staff. People were also involved in choosing furniture and recruiting staff.
The home was rated Good for Safe and Well-led. The previous rating was Requires Improvement, with breaches of regulation. Inspectors found enough improvement had been made and that the home was no longer in breach. The other areas were not inspected during this visit, so their previous ratings were used for the overall rating.
Risk management
Risks to people’s safety and welfare were assessed, with plans to reduce those risks. Staff said they could access the information they needed.
“Risks associated with people's care had been identified and plans were in place to minimise risk occurring.” from the report
Clean and homely environment
The home had improved its fixtures, fittings and cleanliness. Cleaning schedules were in place, and people were involved in choosing furniture.
“The provider had made changes in line with their refurbishment plan, replacement flooring could now be effectively cleaned.” from the report
Safe staffing and recruitment
Inspectors found enough staff to provide safe care and robust checks before staff started work. People were involved in recruiting staff.
“There were enough staff to ensure people received safe care.” from the report
Positive culture
People and relatives spoke positively about the manager and staff. Inspectors found the culture was open, honest and person-centred.
“The provider had an open and honest culture.” from the report
Management systems could be stronger
minorInspectors said some areas still needed improvement so that management systems were more robust. The overall judgement remained Good.
“Whilst the inspection identified some areas where further improvements could be made to develop more robust systems, overall, the service was well managed and led.” from the report
- 01What further improvements are being made to develop more robust management and monitoring systems?
- 02How are risk assessments kept up to date when a person’s needs or risks change?
- 03How do you check that medicines given only when needed are recorded correctly?
- 04How are cleaning schedules and the condition of flooring and other fixtures checked now?
- 05How do people and relatives continue to give feedback and influence improvements?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 10 February 2023 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, June 2019
Rated Requires Improvement; inspectors found kind, effective care but unsafe cleanliness and weak quality checks.
Inspectors visited on 26 and 29 April 2019 without giving notice. They spoke with people, staff and managers, observed care, toured the home, and checked care records, medicines, recruitment, training, complaints and audits. The provider could not complete its information return because of technical problems.
People were generally positive about the care. Staff were kind, respected privacy and dignity, supported people's choices and provided activities, healthcare and medicines appropriately. Food and meal choices were also praised.
The home was not always clean or hygienic. Some furniture, flooring and equipment were worn, damaged or rusty. Emergency evacuation plans were missing and some risks were not properly managed. Care plans did not always match people's needs, and quality checks had failed to find these problems. The overall rating was Requires Improvement, with Safe and Well-led also Requires Improvement. Effective, Caring and Responsive were rated Good.
Kind and respectful staff
People were happy with the care and trusted staff. Inspectors found that staff treated people with compassion and protected their dignity and privacy.
“Staff interacted positively with people. We observed people were relaxed as they were talking, laughing and singing with each other and with staff.” from the report
Personalised support
Staff knew people's routines, preferences and support needs. People were helped to make choices, stay independent and take part in hobbies and community activities.
“People confirmed staff provided care in line with their wishes and personal preferences.” from the report
Medicines and healthcare
People received their medicines as prescribed and staff supported access to healthcare professionals when needed.
“Medicines systems were organised, and people received their medicines when they should.” from the report
Food and choice
People praised the fresh food and range of choices. They could have food that suited their preferences and, where appropriate, cook for themselves.
“People were complimentary of the food and the choices available.” from the report
Cleanliness and equipment
seriousSome equipment was dirty and some furniture and flooring were worn, damaged or rusty. This created a risk of infection and meant the environment was not always safe.
“Areas of the home were not always clean and placed people at risk of developing infections.” from the report
Risks and emergency planning
seriousPersonal emergency evacuation plans had not been completed. Radiators were not consistently covered and risk assessments did not always show when further action was needed.
“Personal emergency evacuation plans had not been completed. This meant people were at risk of not getting the right support in an emergency.” from the report
Weak quality checks
seriousThe home's audits and checks did not reliably identify or fix problems with infection control, equipment, risks and care records. This was a breach of the good governance regulation.
“The provider had failed to operate effective systems to monitor and improve the quality and safety of the service.” from the report
Care plans not always accurate
needs fixingStaff understood people's needs, but records did not always describe the support required. One care plan was updated during the inspection after a gap was identified.
“Staff were knowledgeable about the care and support people needed but care plans did not always reflect this.” from the report
- 01Have all dirty or damaged shower chairs, toilet frames, pressure-relief equipment, furniture and flooring now been cleaned, repaired or replaced?
- 02Have personal emergency evacuation plans been completed for every person who lives here?
- 03What checks now make sure all radiators and other identified risks are managed consistently?
- 04How are care plans and daily records audited to make sure they match each person's current support needs?
- 05How are accidents and incidents now recorded and reviewed so the home can identify patterns and learn from them?
This was an unannounced planned inspection of the premises and care, covering all five CQC questions; the previous inspection on 10 July 2017 had been focused only on Well-led. This explanation was written from the published report of 22 June 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 Somerville House
5 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- February 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- August 2017Goodstayed GoodWell-led: Requires improvement
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 21 December 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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Most charge £1,020 to £1,350 a week. 12 can care for a couple. 8 years' experience on average.
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