CQC report explained · a residential care home
What the CQC found at St Mungo's Broadway - 53 Chichester Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People said they felt safe. Inspectors found safe medicines arrangements, detailed risk assessments, suitable emergency plans and regular fire checks.
- Effective?
- Good
- Staff had completed relevant training and received supervision and appraisals. People had access to healthcare, suitable food and support with nutrition.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. Care records included people's communication methods, choices and preferences.
- Responsive?
- Good
- Care plans were detailed, person-centred and regularly reviewed. People had access to activities, community support and meetings where they could give their views.
- Well-led?
- Good
- The home had a clear management structure and regular quality checks. Staff said managers were supportive and approachable.
What inspectors found, March 2018
Rated Good; inspectors found safe, kind and well-managed care, but the building needed some refurbishment.
This was an unannounced inspection on 9 February 2018. Inspectors reviewed eight care records, seven staff files, training records and management records. They spoke with 11 people living at the home, one relative, managers and six care staff.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and were treated with dignity and respect. Inspectors found safe medicines systems, detailed risk assessments, trained staff, suitable food and access to healthcare.
The home had improved since the previous inspection in February 2017, when it was rated Requires Improvement and had two regulatory breaches. Staff training, appraisals, care plans and quality checks had been strengthened. Inspectors still recommended reviewing the need to refurbish some bathrooms and communal areas.
Improvement since the last inspection
The home acted on the problems found in 2017. Staff training, appraisals, care plans and quality monitoring had improved.
“The service had taken necessary action and made improvements. The service is now rated as "Good".” from the report
Kind and respectful staff
Inspectors observed positive interactions. Staff knew people well, communicated effectively and supported privacy, independence and choice.
“Staff displayed kindness and understanding towards people and addressed them by their preferred names.” from the report
Some areas needed refurbishment
needs fixingInspectors found the bathrooms on the first and second floors needed renovation. Some communal carpets were old and needed replacing.
“The bathrooms on the first and second floor were in need of renovation.” from the report
Window restrictors needed attention
needs fixingOne corridor window restrictor was defective and some bathroom windows needed restrictors. Management said maintenance action would be taken after the inspection.
“We noted that one window restrictor on the first floor corridor was defective.” from the report
Controlled drug recording was being changed
minorControlled drugs were stored and witnessed correctly, but records were kept in a folder instead of a specially designed register. The home ordered a register and started using it after the inspection.
“The service recorded CD administration in a folder instead of a pre-printed specially designed CD register.” from the report
- 01Have the bathrooms and communal carpets been refurbished or replaced since the inspection?
- 02Were all defective or missing window restrictors repaired, and how are these checks monitored now?
- 03How did the planned extra evening staff member from March 2018 change support for people in the evenings?
- 04Are controlled drugs now recorded in a specially designed controlled drug register?
- 05How are people's care plans and risk assessments kept up to date when their needs change?
This was an unannounced inspection covering all five CQC areas, with ratings given for Safe, Effective, Caring, Responsive and Well-led. This explanation was written from the published report of 29 March 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.
What inspectors found, March 2017
St Mungo's Broadway - 53 Chichester Road: Rated Requires Improvement; inspectors found kind care but gaps in staff training, care plans and quality checks.
This was an unannounced inspection on 21 February 2017. Inspectors reviewed six care plans, six staff files, training records and management records. They spoke with people living there, a relative, staff and healthcare professionals.
People generally felt safe and well cared for. Inspectors saw kind and respectful interactions, clean premises, suitable food and access to healthcare. However, risk assessments and care plans did not always contain enough detail. Medicine storage temperatures were not being recorded.
Staff had not all completed important training, including training on the Mental Capacity Act. Staff had not received appraisals in 2016. The home’s quality checks had not identified these problems. The overall rating was Requires Improvement, down from Good at the previous inspection in November 2014.
Kind and respectful care
Inspectors saw staff speaking gently and responding calmly when someone became upset. People were supported with privacy, dignity and choice.
“Care staff were attentive and talked in a gentle and pleasant manner when communicating with people.” from the report
People felt safe
People, a relative and care professionals told inspectors they had confidence in the safety of the home. Staff understood how to recognise and report abuse.
“All care staff we spoke with were clearly able to describe the process for identifying and reporting concerns” from the report
Clean premises
The home was clean and tidy, with infection control measures and cleaning arrangements in place.
“During the inspection we found the premises were clean and no unpleasant odours were noted.” from the report
People could give their views
Monthly meetings and regular key worker sessions gave people opportunities to discuss care, food, activities and how the home was run.
“Meetings were held monthly for people living at the home where they could give their views on how the home was run.” from the report
Care plans lacked detail
needs fixingSome care support plans did not clearly explain the help people needed with personal care, mobility and communication. Information about preferences and routines also varied.
“We found there was limited information in care support plans about the support that people required in respect of various areas of their care such as personal care, mobility and communication.” from the report
Quality checks missed problems
seriousThe home’s audits did not identify important shortfalls in care plans and staff training. The medicines audit also did not cover several important checks. This was a breach of Regulation 17.
“There were some areas where the quality of the service people received was not effectively checked and the service failed to identify failings.” from the report
Medicine storage temperature
needs fixingThe temperature of the medicine storage cabinet had not been checked and recorded. The provider was asked to start daily recording.
“During the inspection we observed that the temperature of the room where medicines were stored had not been monitored and recorded.” from the report
Activities coordinator post
minorThere was no longer an activities coordinator. Staff said activities were not always possible alongside other work, and the post was under review.
“However, they told us that there was no longer an activities coordinator in post” from the report
- 01Have all staff now completed the training gaps identified, including first aid, medicines management, health and safety and the Mental Capacity Act?
- 02Have staff received regular appraisals since the missed appraisals in 2016?
- 03How do you now make sure each care plan clearly explains support with personal care, mobility, communication, preferences and routines?
- 04Are medicine storage temperatures recorded every day, and do medicines audits now include MAR records, controlled drugs, temperature checks and expiry dates?
- 05What activities are currently available, and how is activity support provided now that there was no activities coordinator?
This was an unannounced inspection covering all five rating questions, with checks of care plans, staff records, training and management records and discussions with people, staff and professionals. This explanation was written from the published report of 17 March 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 St Mungo's Broadway - 53 Chichester Road
3 rated inspections over 3 years: the service has held its Good rating throughout.
- March 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at St Mungo's Broadway - 53 Chichester Road →
- March 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at St Mungo's Broadway - 53 Chichester Road →
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 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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