CQC report explained · a residential care home
What the CQC found at The Good Companions (Cumbria) Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and managed, staffing had improved, recruitment checks were completed and infection control arrangements were suitable. Medicines were managed safely overall, but some records were incomplete.
- Effective?
- Good
- This area was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Outstanding
- This area was not inspected during this focused visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found stronger management, better governance and improved staff morale. Quality checks were in place, although the medicines audit was not robust enough to identify recording problems.
What inspectors found, March 2023
The Good Companions (Cumbria) Limited rated Good; inspectors found safer care and stronger management, but medicines records were not always complete.
This was an unannounced follow-up inspection over three days in February 2023. Inspectors spoke with people, relatives and staff, observed a meal, and checked care records, medicines records, recruitment files and management records.
People and relatives described the home as warm, welcoming and homely. They said staff were kind, helpful and available. Inspectors found that risks were assessed, staffing levels had improved, the building was clean and safety checks were up to date.
Medicines were generally managed safely, but some records were not completed correctly. The home’s medicines audit had not identified these issues, so inspectors recommended improving the audit tool.
The overall rating was Good. The inspection directly assessed Safe and Well-led. The other ratings were carried forward from the previous inspection, and the overall rating improved from Requires improvement because earlier legal breaches had been addressed.
Kind and personalised care
People and relatives described staff as kind, friendly and helpful. Relatives said care was personalised and treated each person as an individual.
“The best thing about the home is they treat mum as an individual. She gets really good personalised care” from the report
Improved safety
Risks were assessed and action was taken to reduce avoidable harm. Building safety checks were up to date and lessons were learned from accidents and incidents.
“The registered manager had introduced a better care planning system which included clear risk assessments and measures to reduce avoidable harm.” from the report
Enough staff
Inspectors found there were enough staff to support people. People and relatives said staff were available and responded quickly to call buttons.
“Relatives commented, "Staff respond to the call buttons quickly and they make regular night visits to check on my family member” from the report
Stronger leadership
The registered manager had improved the stability and organisation of the home. Staff said morale and communication had improved.
“The registered manager had been in post for less than a year. They had made noticeable improvements to the stability and governance of the service.” from the report
Good involvement
People, relatives and staff were invited to give their views. A monthly review system gave relatives regular opportunities to discuss care.
“The registered manager had introduced a 'resident of the day' system so that at least once a month each person’s care was reviewed” from the report
Medicines records
needs fixingMedicines were generally managed safely, but some recording issues remained. The issues were discussed with the registered manager and addressed during the inspection.
“Some minor recording issues were discussed with the registered manager and addressed immediately.” from the report
Medicines audit
needs fixingThe home’s medicines audit did not reliably identify recording shortfalls. Inspectors recommended reviewing the audit tool.
“The medicines audit was not sufficiently robust to identify medicines record shortfalls.” from the report
- 01What changes have been made to medicines recording since the inspection?
- 02How do you now check that medicines records are complete and accurate?
- 03How are risks for my relative assessed and reviewed when their needs change?
- 04How will you involve me in regular reviews of my relative’s care?
- 05What improvements have been made since the previous Requires improvement rating?
This was a focused follow-up inspection of Safe and Well-led, with infection prevention and control also reviewed; the other ratings were carried over from the last comprehensive inspection. This explanation was written from the published report of 4 March 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, January 2022
Requires Improvement; inspectors found caring staff and improved infection control, but gaps in risk records, medicines checks and management oversight could put people at risk.
This was an unannounced focused inspection on 25 November and 3 December 2021. Inspectors looked at Safe and Well-led because of concerns about infection control during a COVID-19 outbreak and how the home was managed.
The home was clean and comfortable. Staff were described as kind and caring, and infection control had improved after advice from a health protection nurse. However, risk assessments were not detailed enough, some incidents were not properly reviewed, and medicines checks were not always complete.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were used in the overall rating.
Kind and caring staff
Relatives and staff described a friendly, welcoming and caring culture. Staff were observed engaging with people.
“The provider and staff team promoted a friendly, welcoming culture.” from the report
Improved infection control
The home had PPE, visitor screening and infection control procedures. Inspectors found that practices had improved after advice following the COVID-19 outbreak.
“The home's practices and screening had improved following their input.” from the report
Clean environment
The home was clean and comfortable, and a deep clean was taking place during the inspection.
“During the inspection a deep clean was taking place of the premises.” from the report
Good health and social care links
The home worked well with local health care agencies to support people's needs and wellbeing.
“The service had good working relationships with local health care agencies.” from the report
Incomplete risk assessments
seriousRisk assessments did not always explain the possible impact of risks or the actions staff should take. New risks, including significant weight loss, were not always assessed or recorded.
“People's risk assessments were not sufficiently detailed to understand what impact the risk could have, what the measures were for reducing the risk, and what actions staff should take if the risk occurred.” from the report
Incidents were not properly reviewed
seriousThe safeguarding log had not been completed for a long period. Some incidents were not reported as required, and accidents such as falls were not analysed for patterns or lessons.
“There had been no analysis of accidents or incidents, for example of falls.” from the report
Weak management oversight
seriousAudits did not identify some of the problems found by inspectors. Some repairs and safety actions had been delayed, and staff were not always clear about who managed the home.
“The provider's audits had not identified the shortfalls we found during this inspection, including medicines matters and safeguarding reports.” from the report
- 01What has been changed so each person's risks, including weight loss, are assessed, recorded and reviewed?
- 02How are accidents, falls and safeguarding incidents now recorded, reported and checked for repeated patterns?
- 03How are medicines temperatures, as-required medicine instructions and prescribed creams checked?
- 04Have the fire doors been replaced, and are hot water safety checks now carried out at all relevant outlets?
- 05Who is currently responsible for managing the home, and how do staff receive clear and consistent instructions?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 25 January 2022 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 The Good Companions (Cumbria) Limited
4 rated inspections over 7 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
Read what inspectors found at The Good Companions (Cumbria) Limited →
- January 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at The Good Companions (Cumbria) Limited →
- April 2021Inspected but not ratedSafe: Inspected but not rated
- May 2018Goodstayed GoodSafe: GoodWell-led: Good
- April 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 6 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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