CQC report explained · a residential care home
What the CQC found at Stradbroke Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, October 2023
Stradbroke Court was rated Inadequate and placed in special measures after inspectors found serious safety, staffing and management failures.
This was an unannounced focused inspection on 3 August 2023. Inspectors reviewed safety, effectiveness and leadership because of concerns about safety and a high number of safeguarding referrals. They spoke with people, relatives and staff, observed care, and checked care records, medicines, training and management records.
Inspectors found that risks linked to falls, diabetes and choking were not always properly assessed or managed. There were not enough suitably skilled staff, and the home had a high number of unwitnessed falls. Safeguarding incidents were not always reported, including concerns about sexual safety. Infection control and the condition of the building also needed improvement.
The home did manage medicines safely and carried out suitable recruitment checks. However, care records, mental capacity decisions, staff training, food monitoring and health professional guidance were not always complete or up to date. The provider increased staffing and introduced some immediate changes after the inspection.
The overall rating fell from Good at the previous inspection to Inadequate. Safe and well-led were rated Inadequate, while effective was rated Requires Improvement. The home was placed in special measures, so CQC will monitor it and normally re-inspect within six months.
Medicines
Inspectors found systems for storing, giving and managing medicines safely. Records showed people received their medicines as required.
“There were systems in place for the safe storage, administration and management of medicines.” from the report
Recruitment checks
The home had carried out the required recruitment checks, including checks through the Disclosure and Barring Service.
“Records showed staff had been recruited safely, including making the required checks.” from the report
Action after inspection
The new management team responded to the inspection findings. Staffing was increased and some records and safety arrangements were changed after the visit.
“The new management team had been responsive to the concerns raised by us, and acted promptly to rectify these.” from the report
Access to healthcare
People were referred to health professionals when there were concerns about their wellbeing. Relatives said staff were quick to contact doctors or nurses when needed.
“Relatives told us their family members were supported to access health professionals where required.” from the report
Incomplete risk information
seriousCare records did not always explain how to manage risks linked to falls, choking, diabetes and mental health needs. This meant staff did not always have the information needed to provide safe care.
“Not having the correct guidance for staff placed people at increased risk of harm.” from the report
Staffing and falls
seriousThere were not enough staff with the right skills to keep people safe and provide timely support. The home had a high number of unwitnessed falls, and there were concerns about night-time evacuation.
“We were not assured there were enough staff working in the service to ensure they were always available to keep people safe and provide timely support where required.” from the report
Safeguarding
seriousTwo incidents had not been reported as required, and action to reduce risks linked to sexual safety had not always been prompt. There were four current alleged safeguarding incidents under investigation.
“We were not assured all safeguarding incidents were reported as required.” from the report
Poor records and oversight
seriousThe provider's monitoring systems had not identified and corrected important problems quickly enough. Risk assessments, care plans and mental capacity records were not reliably complete or current.
“Accurate, complete and contemporaneous records were not reliably maintained.” from the report
Mental capacity decisions
seriousCapacity assessments and best-interest decisions were missing or contradictory in some records. Older applications for Deprivation of Liberty Safeguards had not always been followed up.
“Therefore, we were not assured the service had robust systems in place to assess capacity and ensure decisions had been made in people's best interests.” from the report
Environment and infection control
needs fixingParts of the building were poorly maintained, with worn carpets, chipped paint, malodours and areas that could not be cleaned effectively. Personal protective equipment was stored near a toilet, creating a cross-contamination risk.
“We found the environment to be poorly maintained in many areas including worn carpeting and chipped paint on the walls, which did not support effective cleaning.” from the report
- 01What has changed in staffing levels during the day and at night since the inspection, and how do you check that staffing is safe for people's needs?
- 02How are falls, choking and diabetes risks now assessed, recorded and reviewed for each person?
- 03Which safeguarding incidents were reported after the inspection, and what safeguards are now in place for sexual safety and people entering other people's rooms?
- 04Have all mental capacity assessments, best-interest decisions and outstanding Deprivation of Liberty Safeguards applications been reviewed and recorded?
- 05What work has been completed to improve the building, cleaning arrangements and storage of personal protective equipment?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected, and the report says the ratings for uninspected questions carried over from the previous inspection. This explanation was written from the published report of 28 October 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, December 2019
Rated Good; inspectors found people safe, with improved management oversight and some improvement work still under way.
This was an unannounced focused inspection after concerns about people's health, safety and welfare. The inspector looked only at Safe and Well-led. They spoke with two people, two care staff and managers, and checked care records, staff files, recruitment records and quality monitoring systems.
The inspectors found that people were safe. Staffing levels met people's needs, medicines were managed safely, risks were assessed, and the home was clean. Staff understood safeguarding procedures and accidents were reviewed so action could be taken to reduce repeat incidents.
The new manager and regional manager had introduced stronger checks and an improvement plan. The inspectors found the home was now well-led. However, they identified that recruitment checks had not always been strong enough before the new management team started, and some improvement work was still ongoing.
The overall rating stayed Good, the same as at the previous inspection in 2017. The Safe and Well-led ratings were Good. The other three areas were not inspected at this visit, so their previous ratings were used.
Safe staffing
People and staff said staffing levels were suitable. Staffing was kept under review and adjusted when people's needs changed.
“People told us they felt there were enough staff to meet their needs.” from the report
Medicines and risk
Medicines were managed safely, and risks to people and the environment were assessed and monitored.
“Medicines were managed and administered safely. Risks to people were identified, monitored and managed.” from the report
Clean environment
The home was hygienically clean, with infection control checks and suitable protective clothing for staff.
“We observed that the service was hygienically clean and free from odours.” from the report
Improved oversight
The new management team had introduced detailed audits and a plan to address areas needing improvement.
“There was a robust quality assurance system in place which was capable of identifying areas for improvement.” from the report
Earlier recruitment checks
needs fixingRecruitment procedures before the new management team started were not strong enough, and evidence of some criminal records checks was missing. The report says action had been taken to make current recruitment safer.
“They identified that recruitment procedures before the new management team started had not been robust enough and that evidence of appropriate criminal records checks was not present.” from the report
Improvement work ongoing
minorThe managers had identified several areas for development, including care planning, daily records, medicines and building maintenance. The action plan was still being carried out.
“A thorough and robust action plan had been put in place stating how each area for improvement would be addressed and this was ongoing.” from the report
- 01Which actions from the improvement plan are still outstanding, and when will they be completed?
- 02How do you check that every new staff member has the required criminal records checks before starting work?
- 03Who is currently responsible for the home while the new manager is registering with the CQC?
- 04What changes were made after audits identified issues with care planning, daily records, medicines or building maintenance?
- 05How are the views of residents, relatives and staff now being collected and acted on?
This was an unannounced focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous comprehensive inspection. This explanation was written from the published report of 25 December 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.
Every inspection of Stradbroke Court
5 rated inspections over 7 years: the service has slipped, from Requires improvement to Inadequate.
- October 2023Inadequatecurrent ratingdown from GoodSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Inadequate
- December 2019Goodstayed GoodSafe: GoodWell-led: Good
- December 2017Goodup from InadequateSafe: GoodEffective: GoodWell-led: Requires improvement
- July 2017Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- February 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2015
Registered with the Care Quality Commission on 4 September 2015.
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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