CQC report explained · a residential care home
What the CQC found at Susan Hampshire House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2023
Requires Improvement; inspectors found caring, person-centred support but weaknesses in safety checks and quality monitoring.
The inspection took place on 6 and 13 December 2022. It was unannounced on the first day, with 24 hours' notice for the second day. Inspectors spoke with people, staff, relatives and a health or social care professional. They also observed care and checked records.
People were generally supported to make choices, stay in contact with relatives and take part in activities. Inspectors found enough staff, safe medicines arrangements and staff who understood safeguarding. However, food hygiene records, some premises and infection control arrangements needed improvement.
The home's checks had not found these problems. Inspectors said the systems for monitoring quality and safety were not effective. Some issues were fixed during the inspection, but the overall rating changed from Good at the previous inspection to Requires Improvement.
Only Safe and Well-led were inspected this time. The ratings for the other three questions were carried forward from the previous inspection.
Person-centred support
People were supported to make choices, do activities they liked and live as ordinary a life as possible. Staff knew people well and promoted independence.
“People were supported to do the things they liked to do.” from the report
Enough staff
Inspectors found suitable staffing levels, with staff saying there were usually four staff during the day. Recruitment, induction and training arrangements promoted safety.
“People were cared for by suitable numbers of staff.” from the report
Safe medicines
Medicines were ordered, stored, given and disposed of safely. Staff supported people to make their own decisions about medicines where possible.
“People received their medicines safely.” from the report
Positive relationships
Inspectors saw people relaxed and comfortable with staff. Relatives spoke positively about the care and the support for activities and outings.
“There was a positive culture in the home, where people were supported to make decisions on how they wanted to be supported and their views were sought.” from the report
Food hygiene records
needs fixingThere were not enough records to show that food had been cooked to the correct temperature. Fridge and freezer temperature records also had gaps.
“There was a lack of records demonstrating that foods had been cooked to the correct temperature.” from the report
Premises and infection control
needs fixingSome lounge furniture was ripped or missing covers, making it difficult to clean. Some mattresses, bins and bathroom staining also needed attention, although several issues were addressed during the inspection.
“Some of the lounge furniture in the lounge and conservatory was ripped and one seat had no cover.” from the report
Weak quality monitoring
seriousThe home's audits had not identified the safety and premises problems found by inspectors. Some records were missing, out of date or not kept in the expected files.
“The provider had failed to ensure effective systems were in place to monitor the quality and safety of the service.” from the report
- 01What action has been taken to keep complete records of cooking temperatures and fridge and freezer temperatures?
- 02How are you now checking that furniture, mattresses, bins, bathrooms and other areas remain clean and suitable?
- 03What quality audits are currently completed, and how do you make sure they identify problems promptly?
- 04What progress has been made on the planned roof work, fire doors, evacuation chair training and night evacuation arrangements?
- 05Have the planned replacements for the tired sofas and dining tables been approved and completed?
This was a focused inspection of Safe and Well-led only; the other three ratings were carried forward from the previous inspection. This explanation was written from the published report of 18 January 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, July 2018
Rated Good; inspectors found safe, kind and personalised care, with some staffing and activity improvements still being worked on.
Inspectors visited without warning on 3 July 2018. They spoke with people living at the home, relatives, staff and health professionals. They reviewed care records, medicines records, staffing rotas, training and checks on the service.
The home provided accommodation and personal care for people with learning disabilities. Inspectors found people were safe, treated with kindness and supported to make choices. Care plans had been improved and staff understood people's needs, routines and preferences.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. The previous inspection in 2017 had found a breach and rated the service Requires Improvement overall. Inspectors found the required improvements had been made.
Safe medicines support
Staff were trained and their competence was checked before they gave medicines independently. Records included people's preferences, allergies, side effects and instructions for medicines given when needed.
“All staff who gave medicines to people had their competency assessed by the registered manager or the assistant manager.” from the report
Personalised care
Staff understood people's routines, interests and support needs. Named staff allocations and improved care plans helped make support more individual.
“People had a support plan, which detailed the support they needed, which was personal to them.” from the report
Community activities
People were supported to take part in local groups, trips, holidays and activities linked to their interests. They were involved in choosing what to do.
“People had access to a range of activities included accessing the local leisure centre, participating in a local dementia awareness group that was open to all the community, theatre and cinema trips, gardening, arts and crafts, cookery, photography and sing along groups.” from the report
Improved oversight
The home had regular quality checks and action plans. These helped identify and track improvements to care plans, records and staff support.
“There were a variety of reviewing and monitoring systems to ensure the quality of care was maintained and improved.” from the report
Vacant staff posts
needs fixingThe home was recruiting to three vacant posts. Inspectors found staffing was sufficient at the visit, but the family should ask how vacancies affect consistency and planned support.
“The registered manager told us they were actively recruiting to three vacant posts.” from the report
Some supervision was overdue
minorOne staff member was overdue for formal supervision, although an action plan was in place and they said they felt supported. Ask whether all planned supervision is now taking place.
“One member of staff told us they were overdue for a formal supervision, but this was because of annual leave.” from the report
Activities being reviewed
minorThe home recognised that some people had been doing the same social activities for many years. It was planning more one-to-one activities and reviewing whether existing groups were still meaningful.
“They were also reviewing and introducing new clubs as it was recognised that some people had been attending the same social activities for many years.” from the report
Complaints about group living
needs fixingThere had been 16 complaints in the previous 12 months, mainly about other people living at the home. The home was working with the community learning disability team on behaviour plans and staff training.
“The major theme from the complaints we have received have been people complaining about other people living at Susan Hampshire House” from the report
- 01How have the three vacant staff posts affected staffing, agency use and consistency of care since the inspection?
- 02Are staff supervisions now taking place every four to six weeks as planned?
- 03What new one-to-one activities or clubs have been introduced since the review of activities?
- 04How are complaints and difficult relationships between residents being managed now?
- 05What decision was made about continuing the short-break service, and how are existing residents being consulted?
This was an unannounced inspection of the overall service, including all five CQC questions, care records, staffing, medicines, training, quality checks and people's experiences. This explanation was written from the published report of 25 July 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 Susan Hampshire House
4 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- January 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- July 2017Requires improvementstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 5 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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39 live-in carers within about an hour of South Gloucestershire
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Most charge £1,020 to £1,280 a week. 32 can care for a couple. 11 years' experience on average.
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