CQC report explained · a residential care home
What the CQC found at South Hayes Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks to people and the building had been identified, assessed and reviewed. Medicines, staffing, safeguarding and accident reporting were also managed safely.
- Effective?
- Good
- This area was not inspected during this focused visit. Its rating was carried over from the previous inspection.
- Caring?
- Good
- This area was not inspected during this focused visit. Its rating was carried over from the previous inspection.
- Responsive?
- Good
- This area was not inspected during this focused visit. Its rating was carried over from the previous inspection.
- Well-led?
- Good
- Inspectors found effective governance systems, regular audits and a consistent management team. People, relatives and staff said managers were approachable and that communication was good.
What inspectors found, January 2024
Rated Good after improving from Inadequate; inspectors found safe care and stronger management, but bowel monitoring still needed more detail.
Inspectors visited without notice on 6 December 2023. They spoke with people living at the home, relatives and staff. They reviewed care and medicine records, recruitment checks, training, rotas, handover documents and environmental checks.
The home had improved since the previous inspection. Risks in the building were assessed and addressed. Medicines, staffing, safeguarding and accident reporting were managed safely. People and relatives said they felt safe, and staff were described as caring and approachable.
The inspection focused only on Safe and Well-led. Both were rated Good. The overall rating changed from Inadequate to Good, using the new findings together with ratings from the previous inspection for the areas not inspected.
Safer environment
The home had made several environmental improvements, including safer equipment storage, corrected window restrictors and covered radiator pipes.
“The provider had made improvements to the environment since our last inspection.” from the report
Medicines managed safely
Staff received medicine training and competency checks. Medicines were stored safely and monthly audits were completed.
“People were supported to receive their medicines safely.” from the report
Caring staff
Inspectors found staff knew people well and treated them with care and compassion. People and relatives also said staff were friendly and caring.
“People were supported by caring and compassionate staff who knew them well.” from the report
Stronger management systems
The provider had introduced better audits and systems to monitor care and the environment. The home was working within its registration conditions at this inspection.
“At this inspection we found there were effective governance systems in place to monitor the quality of care and the safety of the environment.” from the report
Bowel monitoring needed more detail
minorInspectors said bowel records needed a clearer overview so staff could take timely action if someone needed further help. The registered manager changed the monitoring system during the inspection.
“Further development was needed with monitoring bowel records, whilst people's care plans were detailed and gave a good description of individual support needs, a more detailed overview was required” from the report
- 01What changes were made to bowel monitoring after the inspection, and how are managers checking that records are complete?
- 02How are the new environmental checks and governance audits kept up to date?
- 03What are the current ratings for Effective, Caring and Responsive, which were not assessed during this visit?
- 04How do you check that staffing levels remain sufficient and that people respond promptly to call bells?
- 05What evidence shows that the improvements made after the previous Inadequate inspection have been maintained?
This was an unannounced focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection. This explanation was written from the published report of 18 January 2024 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, August 2023
Overall rating remains Inadequate; a targeted inspection found some improvements but people remained at risk from unsafe areas and fire evacuation arrangements.
This was an unannounced targeted inspection on 22 June 2023. Two inspectors checked fire safety, building checks, staff recruitment, medicines storage and the safe storage of hazardous items. They spoke with three staff and reviewed records.
The home had completed actions required by the fire and rescue service. Medicines were stored safely, recruitment checks had improved and some cleaning work had been done. However, two people had been moved to the top floor without suitable fire evacuation equipment.
Inspectors also found unsafe stairwells, exposed hot pipes, unsecured wardrobes, clutter, unsafe storage and access to hazardous substances. They said the home's checks had failed to identify these risks. The home remained in breach of Regulation 12 and Regulation 17.
This inspection was targeted, so it did not review every part of the service. It did not change the previous overall rating of Inadequate. The Safe and Well-led questions were inspected but not re-rated.
Fire safety work
The provider had completed the actions required by the fire and rescue service. Fire doors had been replaced and further fire prevention work was under way.
“The provider had completed the actions required by Hereford and Worcester Fire and Rescue Service.” from the report
Safer recruitment
Inspectors found that recruitment processes had been reviewed and staff were being recruited safely.
“Recruitment processes had been revaluated and the provider was safely recruiting people into the service.” from the report
Medicines and cleanliness
Medicines were stored safely. Inspectors also saw action to improve infection control and cleanliness in rooms and communal areas.
“The provider had taken action to improve infection control throughout the home.” from the report
People remained at risk from the building
seriousTwo people had been moved to the top floor without suitable fire evacuation equipment. Inspectors also found unsafe stairwells, exposed hot pipes, unsecured wardrobes, clutter and other hazards.
“Some people remained at risk of harm as the provider had failed to provide sufficient fire evacuation equipment and safely secure stairwells.” from the report
Weak safety oversight
seriousThe provider's checks failed to identify several hazards, including access to hazardous substances and open stairwells. Inspectors said further improvements and stronger oversight were needed.
“Further improvements and provider oversight were required to ensure effective management of people's safety.” from the report
- 01What fire evacuation equipment is now available for people living on the top floor?
- 02How have the open stairwells and risks of falls from height been made safe?
- 03Have the exposed radiator pipes, unsecured wardrobes, clutter and trailing wires all been fixed?
- 04How is access to hazardous substances now controlled?
- 05What checks are now in place to make sure the provider identifies and fixes safety risks?
This was a targeted inspection of specific fire safety, safe care and provider oversight concerns; it did not assess the whole Safe or Well-led questions and did not review the other three questions. This explanation was written from the published report of 23 August 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.
Every inspection of South Hayes Care Home
4 rated inspections over 8 years: the service has held its Good rating throughout.
- January 2024Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2023Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- June 2023Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- March 2019Goodstayed GoodSafe: GoodWell-led: Good
- May 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 12 January 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.
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