CQC report explained · a residential care home
What the CQC found at Lees Hall Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment checks, detailed risk assessments and safe medicines processes. Staff understood safeguarding and how to respond to possible abuse.
- Effective?
- Good
- Staff had relevant training, supervision and support. People were helped with food, healthcare appointments and choices about how they spent their time.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff supported privacy, independence and people's cultural and personal needs.
- Responsive?
- Good
- Care plans were clear and personalised. People were supported with their interests and community access, although staff said it could be difficult to motivate some people to take part in activities.
- Well-led?
- Good
- The home had a registered manager and deputy manager, regular checks and audits, and systems for learning from incidents and improving care.
What inspectors found, April 2019
St Anne's Community Services - Lees Hall Road was rated Good; inspectors found safe, kind and person-centred care, with some building issues to watch.
Inspectors made an unannounced visit on 3 April 2019. They spoke with people living at the home, managers and support workers, and reviewed care, medicines, staff and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, trained staff, personalised care and good support for people to make choices and stay independent.
The report also noted some areas needing attention. Parts of the building needed refreshing, the shower was reported to keep breaking down, and all bedrooms were upstairs with no lift. The home did not provide end of life care.
This was a planned inspection to check that the previous Good rating had been maintained. The previous inspection, published in October 2016, had also rated the home Good.
Enough staff
Inspectors found staffing levels were sufficient and rotas allowed flexibility for appointments. Staff also covered vacant shifts so people could be supported by workers they knew.
“There were sufficient staff to meet people's needs; people using the service, and staff confirmed this.” from the report
Safe medicines
Medicines were received, stored, given and disposed of safely. Staff were trained and checked for competence, and medicines were counted after administration.
“Medicines systems were organised, and people were receiving their medicines when they should.” from the report
Choice and independence
People were supported to make choices, manage parts of their daily lives and take positive risks without unnecessary restrictions.
“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
Kind and respectful care
People appeared comfortable with staff and said they were happy. Staff respected privacy, knocked before entering rooms and encouraged independence.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Personalised support
Care plans described people's needs and preferences. Staff helped people pursue interests, shop and access the community where this was part of their assessed support.
“People's care plans were clear and provided detailed assessments of people's support needs and how they wanted their support to be provided.” from the report
Shower repairs
minorOne person said the shower kept breaking down. Families should ask about the current condition of the shower and how repairs are managed.
“Nothing springs to mind except the shower keeps breaking down.” from the report
All bedrooms upstairs
minorThere was no lift to the bedrooms. The manager said the ground-floor staff sleepover room could be considered for a person who could no longer manage the stairs.
“All bedrooms were based on the first floor accessed via two staircases. There was no lift between floors.” from the report
- 01What has been done to repair the shower since the inspection, and how are future repairs reported and monitored?
- 02Which areas of the home have been refreshed since the inspection, and is there now a refurbishment plan?
- 03If my relative became unable to use the stairs, what accommodation and support would be available?
- 04How would you involve my relative in reviewing their care plan if they did not want to attend a formal review?
- 05What approaches do staff use when someone is difficult to motivate or engage in activities?
This was an unannounced planned inspection of the whole service, covering all five CQC questions and both the premises and care provided. This explanation was written from the published report of 27 April 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, October 2016
Rated Good; inspectors found kind, person-centred support, with some discrepancies in medicine stock counts.
The announced inspection took place on 27 July 2016. Two inspectors spoke with three people using the service, two care staff and the manager and deputy manager. They observed care, looked around the home and reviewed care records, staff files, audits and other documents.
The inspectors found people were safe and supported by enough staff at the time. Safeguarding, risk assessments, accident reporting, recruitment and cleanliness were good. Medicines were administered correctly, but there were some discrepancies in the stock counts checked.
People were involved in their care plans and recovery goals. Staff were trained and supervised. The inspectors saw friendly, respectful support, activities and help with independence. Complaints arrangements and quality checks were in place.
The overall rating was Good. Safe, Effective, Caring, Responsive and Well-led were all also rated Good. The manager was not yet registered with the CQC but was part way through the registration process.
Person-centred care
Care plans were written in plain English and included people's preferences, goals, risks and recovery needs. People were involved in reviewing them.
“People who used the service had ownership of their care plans and were involved in the process.” from the report
Kind and respectful staff
Inspectors saw a relaxed atmosphere and staff interacting with people in a positive, encouraging and respectful way.
“We saw people were respected by staff and treated with kindness.” from the report
Support for independence
People were helped to build daily living skills, use public transport, access the community and work towards longer-term independence.
“During our inspection we were able to see how the people who used the service were supported to be independent and to work towards a longer term goal to live independently.” from the report
Trained staff
Staff received a range of training, regular supervision and annual appraisals. New staff had an induction and time shadowing experienced colleagues.
“We found staff were trained, skilled and experienced to meet people's needs.” from the report
Quality monitoring
The home used audits, staff meetings, engagement meetings and an annual survey to review the service and identify improvements.
“We found the service had been regularly reviewed through a range of internal and external audits.” from the report
Medicine stock counts
needs fixingInspectors found discrepancies in the stock counts of some medicines, even though the records showed medicines were being administered correctly.
“However there were some discrepancies with the stock counts of medicines we looked at.” from the report
Manager registration
minorThe manager was in post but had not yet registered with the CQC. The report says the application was in progress and awaiting an interview.
“At the time of our inspection visit, the home had a manager in place but was not registered with us.” from the report
Recruitment was ongoing
minorThe home was not yet fully staffed. Inspectors considered staffing sufficient at the time because the home was not full.
“We were told that recruitment was an on-going process with the service not yet fully staffed.” from the report
- 01What action has been taken since the inspection to prevent discrepancies in medicine stock counts?
- 02Is the manager now registered with the CQC?
- 03Has recruitment been completed, and what staffing levels are in place now?
- 04How will you involve my relative in reviewing their care plan and recovery goals?
- 05What activities and community opportunities would be available for my relative?
This was an announced inspection covering the overall service and all five CQC questions, including observations, discussions and reviews of care and staff records. This explanation was written from the published report of 6 October 2016 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 Lees Hall Road
2 rated inspections over 3 years: the service has held its Good rating throughout.
- April 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- January 2013
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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