CQC report explained · a residential care home
What the CQC found at St Peters Row Delarue Close
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Staffing levels, recruitment, medicines, equipment and infection control were judged safe, although hoisting information needed updating and a previous fire drill had caused delay and confusion.
- Effective?
- Good
- Care was based on people's needs and choices. Staff had relevant training, people received support with food, health appointments and communication, and the home worked with health professionals.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff supported people to communicate, make decisions, develop independence and maintain important relationships.
- Responsive?
- Good
- Support plans reflected people's preferences, abilities, needs and goals. People were supported with activities, holidays, relationships and communication in ways that suited them.
- Well-led?
- Good
- The home had an open and positive culture. Management systems checked care quality, accidents, medicines, staffing and safety, and records showed action was taken when issues were found.
What inspectors found, April 2020
St Peters Row Delarue Close was rated Good; inspectors found safe, kind and person-centred care, with minor issues corrected during the visit.
This was an unannounced inspection by one inspector. Inspectors spoke with six people, six relatives, five staff and a community nurse. They observed care and checked support plans, medicines records, risk assessments, staffing records and management systems.
The home supported 15 people with learning disabilities or autism. Inspectors found that people were happy, treated with kindness and supported to make choices, build independence, use community services and maintain relationships. Staff knew people well and relatives were very positive.
All five areas were rated Good: safe, effective, caring, responsive and well-led. Inspectors found enough staff to meet assessed needs, safe medicines systems, suitable training and strong links with health professionals.
There were some staffing vacancies. Inspectors also found that some hoisting assessments did not include the sling size and coloured loops to use, and that a previous fire drill had caused delay and confusion. The hoisting records were changed immediately, and fire procedures and staff induction were reviewed.
Choice and independence
People were supported to make everyday choices, gain skills and take part in ordinary community life. Assistive technology helped some people remain independent while having support nearby.
“The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion.” from the report
Kind relationships
People appeared happy and comfortable with staff. Relatives described the care as kind and said they had confidence in the home.
“People had positive relationships with staff that knew them well.” from the report
Skilled staff
Staff received mandatory and specialist training, supervision and support. Inspectors found that staff understood people's health and communication needs.
“Staff had a full understanding of people's support needs and had the skills and knowledge to meet them.” from the report
Activities and relationships
People could choose from home-based, social and community activities. They were supported to go on holidays and maintain important friendships and family relationships.
“People were supported to go on shopping trips and go out for meals.” from the report
Good management checks
The provider used regular checks, surveys, meetings and reviews to monitor quality and gather views from people, relatives and staff.
“The systems to review and check the quality of the service were robust.” from the report
Hoisting guidance
needs fixingSome hoisting assessments did not state the sling size or which coloured loops to use. The manager made immediate changes after inspectors raised this.
“These had not always showed the size of the sling and which coloured loops to use.” from the report
Fire drill learning
needs fixingA recent fire drill involving agency staff had led to delay and confusion during evacuation. The home reviewed its fire procedures and induction process afterwards.
“There had been a delay to the evacuation and some confusion.” from the report
Staffing vacancies
minorThe home had some vacancies and was recruiting. Bank staff were used when needed, reducing reliance on agency staff.
“The service had some staffing vacancies which they were recruiting to.” from the report
- 01Have the staffing vacancies mentioned in the report now been filled, and how do you maintain familiar staff cover when someone is absent?
- 02How are sling sizes and coloured hoist loops recorded and checked for each person who needs hoisting?
- 03What changes were made after the fire drill that caused delay and confusion?
- 04How will you support my relative to build independence and make everyday choices?
- 05How do you involve relatives and health professionals when a person's needs change?
This was an unannounced comprehensive inspection covering all five CQC questions; all five ratings remained Good, as at the previous inspection. This explanation was written from the published report of 8 April 2020 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 2017
St Peters Row Delarue Close was rated Good; inspectors found safe, kind and personalised care with effective management checks.
This was a comprehensive, announced inspection on 7 July 2017. Inspectors spoke with eight people living at the home, four relatives, staff and local authority case managers. They also reviewed care records, risk assessments, recruitment files, medicines records and quality checks.
Inspectors found that people were protected from abuse and harm. There were enough staff, recruitment checks were thorough, and individual risks were assessed clearly. People were supported with medicines, health appointments, nutrition and specialist care. Staff were described as kind, respectful and knowledgeable.
The home offered personalised support and encouraged people to make choices and develop their independence. People and relatives were involved in care planning and could raise concerns. The management team had systems to monitor quality and make improvements.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. It remained Good after the previous inspection in June 2015 and met all relevant fundamental standards.
Individual risk planning
Risk assessments were based on each person's needs and included clear steps for reducing risks while supporting independence.
“Risk assessments were centred on the needs of the individual.” from the report
Skilled staff
Staff received induction, regular supervision and training linked to people's individual health and support needs.
“People received effective care from skilled, knowledgeable staff.” from the report
Kind and respectful support
Staff encouraged people to do things for themselves while respecting their privacy, dignity and communication needs.
“Staff promoted people's independence and encouraged them to carry out tasks autonomously such as making drinks, preparing food and cooking, processing laundry, planning their activities and taking care of their environment.” from the report
Choice and personalised activities
People's hobbies, interests and choices shaped their activities, outings and daily routines.
“People's hobbies and interests were taken into account and people went out swimming, gardening and farming, dancing and socialising with friends as they wished.” from the report
Quality monitoring
The home used regular audits, meetings and surveys to identify improvements and check that care records and safety systems were maintained.
“A system of quality assurance checks was in place and effectively implemented.” from the report
Staff confidence with mental capacity assessments
needs fixingThe manager was working to make sure all care staff felt confident completing mental capacity assessments. Inspectors noted that staff had been relying on the management team to do this.
“The registered manager was in process of ensuring that all staff providing care were confident with carrying out mental capacity assessments when the need arose, as he had identified that staff relied solely on the management team to do this.” from the report
- 01How have you made sure care staff are now confident completing mental capacity assessments?
- 02How are the new medicines checks and medicine administration records being kept up to date?
- 03How often are each person's risk assessments and care plans reviewed when their needs change?
- 04How are people's and relatives' views from meetings used to make changes to the home?
- 05How do you make sure staff have the specialist training needed for each person's health and communication needs?
This was a comprehensive inspection covering all five questions and the overall quality of the home. This explanation was written from the published report of 23 August 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 Peters Row Delarue Close
3 rated inspections over 5 years: the service has held its Good rating throughout.
- April 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 November 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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