CQC report explained · a residential care home
What the CQC found at Cardigan Road
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines, incident recording and some risk management were not always safe or consistently monitored. There were enough staff, recruitment checks were appropriate, people felt safe and infection control had improved.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its rating was carried forward from the previous inspection.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its rating was carried forward from the previous inspection.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its rating was carried forward from the previous inspection.
- Well-led?
- Requires improvement
- Management checks did not reliably identify and resolve problems with medicines, care records and person-centred support. Staff and people said communication was good, and managers responded to the inspection findings.
What inspectors found, November 2023
Rated Requires Improvement; inspectors found caring staff and enough support, but medicines, records and management checks were not reliable enough.
Inspectors visited on 19 and 24 October 2023. The first visit was unannounced. They spoke with all 8 people living there and 7 staff, observed care, and checked care, medicines, recruitment and management records.
The home was rated Requires Improvement overall. Safe and well-led were both rated Requires Improvement. Medicines were not always managed safely, some incidents were not recorded or reviewed properly, and care records did not always show people's current health and wellbeing.
People said they felt safe and were happy living there. There were enough staff, people were supported to go out, infection control had improved, and staff were described positively. Managers acted promptly when inspectors raised concerns, but the inspection found that existing checks had not fully dealt with several problems.
This was a focused inspection of Safe and Well-led only. The other key question ratings were carried forward from the previous inspection, and the last overall rating was Good in October 2018.
Enough staff
People said there were enough staff to support them at home and in the community. Records showed people went out frequently and funded one-to-one support was provided.
“People told us there was always enough staff available to support them when they were at home and in the community.” from the report
People felt safe and settled
People told inspectors they felt safe and were happy living in the home. Inspectors saw a positive atmosphere and people who were comfortable with staff and others.
“On both days of the inspection we observed there was a nice atmosphere and people were comfortable in their surroundings” from the report
Improved cleanliness
The home had acted on the previous recommendation about cleanliness. Inspectors found it clean and saw safe infection prevention and control practices.
“At this inspection we found the provider had acted on the recommendation and had made improvements.” from the report
Positive staff relationships
Feedback about staff and management was consistently positive. People and staff could share ideas through regular meetings.
“People told us they were happy living at Cardigan Road.” from the report
Support for community life
People were encouraged to take part in social activities and access the community. Inspectors also found that legal safeguards and best-interest decisions were in place where needed.
“People were encouraged to live as full a life as possible in relation to social activities and accessing the community.” from the report
Medicines were not always safe
seriousThere were not always suitable instructions for topical creams and medicines given when needed. Staff did not always follow the guidance that was available.
“People were supported to receive their medicines in a way that was not always safe.” from the report
Incident records were inconsistent
seriousSome incidents were not recorded in the correct format, analysed or used to learn lessons. This could make it harder to prevent similar events.
“However, we saw some incidents had not been recorded using the correct format and were not analysed and lessons were not learned.” from the report
Care records had gaps
needs fixingSome care plans were not up to date, and daily notes and health appointment records were missing. Inspectors said this made it difficult to monitor people's health and wellbeing closely.
“Gaps in care records meant it was sometimes difficult to monitor people's health and well-being.” from the report
Management checks were not effective enough
needs fixingThe home's quality checks had identified some issues but had not fully resolved them. The management structure was not fully supported and governance systems were not always reliable.
“The provider's system did not always effectively monitor the quality of care provided to drive improvements.” from the report
Daily routines were not always personal
needs fixingPeople had good opportunities to go out, but there were fewer opportunities within the home. Involvement in shopping, preparing and cooking meals was limited.
“However, opportunities within the service were less so and routines were not always person centred.” from the report
- 01What new checks are now in place to make sure topical creams and as-required medicines are given safely and staff follow the instructions?
- 02How are incidents recorded, reviewed and used to prevent similar events?
- 03How will you keep care plans, daily notes and health appointment records up to date?
- 04What has been completed from the action plan mentioned in the report, and what remains outstanding?
- 05How will residents be more involved in shopping, preparing and cooking meals and other activities inside the home?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 11 November 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, October 2018
Rated Good; inspectors found safe, caring support, but cleanliness and staff involvement needed improvement.
This was an unannounced inspection over three days in August and September 2018. The inspector visited the home, observed care, spoke with people, relatives, staff and professionals, and checked care, medicines, recruitment, training and quality records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe, staff were kind, medicines were managed safely, and care plans reflected people's needs and choices.
Inspectors found some areas were not clean. They also heard that staff did not always feel involved in decisions and that supervision had not always been regular. Recommendations were made to improve these areas.
The overall Good rating continued from the previous inspection. Safe improved from Requires Improvement to Good, while the other four ratings remained Good.
Personalised care
Care plans focused on each person's needs, routines and preferences. People and their relatives were involved in assessments.
“Care plans were very personalised and focused on the person.” from the report
Kind and respectful staff
People described staff as caring and friendly. Inspectors saw staff respecting privacy, dignity and people's personal choices.
“People looked well cared for, relaxed and happy.” from the report
Safe medicines support
Medicines were stored securely and staff were trained and assessed as competent to administer them.
“Medicines were managed safely. This included there being a sufficient supply of medicines which were stored securely.” from the report
Choice and independence
People were supported to make everyday choices and take part in work, college, shopping, social activities and community life.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.” from the report
Cleanliness
needs fixingSome upholstered furniture and flooring were not clean. Cleaning standards were not routinely monitored, and inspectors recommended improvement.
“We found there were areas of the service which were not clean.” from the report
Staff involvement
needs fixingSome staff felt they were not properly involved in decisions by the management team and provider. Inspectors recommended improving communication and decision-making.
“Staff told us they found the decision-making processes at the service did not always allow for their input.” from the report
Staff supervision
minorStaff gave mixed feedback about supervision, which had not always been as regular as the home's policy required. Inspectors recommended continued work in this area.
“We received mixed feedback from staff regarding their line manager providing supervision.” from the report
- 01What cleaning schedule is now in place, and how do you check that furniture and flooring are kept clean?
- 02How are staff now involved in decisions about the home and how is their feedback recorded?
- 03How often do staff receive supervision, and what happens if a supervision meeting is missed?
- 04How are people's personalised care plans reviewed when their needs or preferences change?
- 05How do you check that staffing levels remain sufficient for the people living here?
This was an unannounced inspection covering all five CQC questions, the premises and the care provided; the report compares the results with the previous inspection in January 2016. This explanation was written from the published report of 27 October 2018 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 Cardigan Road
4 rated inspections over 9 years: the service has held its Requires improvement rating throughout.
- November 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2018Goodstayed GoodSafe: GoodWell-led: Good
- March 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2013
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 15 March 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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Most charge £980 to £1,250 a week. 89 can care for a couple. 11 years' experience on average.
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