CQC report explained · a residential care home
What the CQC found at 34-36 Shaftesbury Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse, risks were known by staff, and there were enough safely recruited staff. Medicines were managed better, although storage temperature checks were not always completed and as-needed medicines did not yet have written protocols.
- Effective?
- Good
- People's needs were assessed before moving in. Staff received training and supervision, supported access to healthcare and helped people make their own decisions.
- Caring?
- Good
- Staff treated people with kindness and warmth. People were involved in their care, supported to stay independent, and treated with dignity and respect.
- Responsive?
- Good
- Care was tailored to people's needs, preferences and goals. Staff responded to changing needs and people knew how to complain.
- Well-led?
- Good
- Managers used audits, peer reviews and action plans to improve the service. Staff and people said managers were approachable and listened, although recording of completed survey actions was not always clear.
What inspectors found, September 2018
Rated Good; inspectors found kind, person-centred care and improvements in medicines and quality checks, with a few records still needing attention.
Inspectors visited on 6 and 9 August 2018 without warning. They observed care, spoke with four people, managers and staff, and checked care plans, medicines records, staffing, training, complaints and quality records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe recruitment, good safeguarding knowledge, clean surroundings and support for people's health and independence.
The home had improved since the November 2017 inspection. Medicines records and quality checks were better, and the previous breaches were no longer present. However, medicines storage temperatures were not always checked, and protocols for medicines given when needed were still to be introduced.
Kind and respectful care
Staff knew people's preferences and supported them with warmth, dignity and compassion. People appeared comfortable and relaxed with staff.
“Staff spoke to people with kindness and warmth and engaged positively throughout our visit, laughing and joking with them.” from the report
Personalised support
People helped create their care plans, risk plans and goals. Staff supported people to make choices and work towards greater independence.
“People were supported to express their views and be involved in decisions related to their care.” from the report
Improved medicines management
The previous medicines breach had been addressed. Records had no unexplained gaps, audits were taking place and staff understood people's medicines risks.
“At this inspection we found improvements had been made” from the report
Good staffing and training
There were enough staff to meet people's needs. Recruitment checks, training, supervision and support were in place.
“There were sufficient staff to meet people's needs and the provider demonstrated safe recruitment processes were followed.” from the report
People's choices and independence
People could come and go, choose how to spend their time and stay in contact with family and friends. Staff supported people to make their own decisions.
“People told us they made their own decisions and came and went as they pleased.” from the report
Medicine storage checks
needs fixingTemperature checks for medicine storage were not always completed. The manager acted during the inspection and checks were seen on the second visit.
“Medicines storage was secure but temperatures checks needed to be done consistently.” from the report
As-needed medicine guidance
needs fixingWritten protocols were not in place for some medicines prescribed to be given when needed. The manager and deputy manager said they would introduce them.
“Some people were on medicines that were prescribed to be given as and when needed (PRN). Whilst staff were aware of when and how to use these medicines, no PRN protocols were in place” from the report
Tracking improvement actions
minorSome actions from surveys had been completed, but the records did not clearly show this. The manager planned to bring actions together in one central record.
“but there was no clear recording of this.” from the report
- 01How are medicine storage temperatures checked now, and what happens if a check is missed?
- 02Are written protocols now in place for every medicine prescribed to be given as and when needed?
- 03How do you record, assign and follow up actions from people's feedback and surveys?
- 04How are people's risk plans and crisis plans reviewed when their mental health needs change?
- 05Who is responsible for the day-to-day management of the home when the registered manager is not working there?
This was an unannounced inspection of the overall service, including care and the premises, and all five CQC questions were rated. This explanation was written from the published report of 8 September 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, January 2018
The You Trust - 34-36 Shaftesbury Road was rated Requires Improvement; inspectors found unsafe medicines management and weak quality checks, although earlier premises concerns had been fixed.
This was an unannounced focused inspection on 10 and 13 November 2017. Inspectors checked whether earlier problems with the building had been fixed, and also looked at safety and leadership. They spoke with four people and four staff, and reviewed care, medicines, staffing, maintenance, incident and quality records.
The home had fixed the earlier breach about unsafe premises. Fire safety, repairs and equipment checks were being managed, and action was taken when risks were found. People said staff were available, understood their needs and helped them manage mental health risks.
However, medicines were not always managed safely. Some risks had not been assessed, medicine records had gaps, and staff did not always follow the home's procedures. Quality checks were also not reliable enough to identify and correct problems. The overall rating was Requires Improvement. Safe and well-led were Requires Improvement, while effective was Good.
Premises safety improved
The home had acted on the previous inspection's concerns about the building. Repairs and safety checks were being followed up, and a broken window was fixed promptly.
“At this inspection we found the provider had made improvements in their system for managing the maintenance of the premises and this was no longer a breach.” from the report
Mental health support
Staff understood people's mental health risks and helped them access appropriate support. Recovery plans were used to support personal goals, including moving towards more independent living.
“People had been supported to manage risks to their mental health and wellbeing.” from the report
Staffing and recruitment
People said staff were available when needed. The home used its own temporary staff to cover absences and followed recruitment checks.
“People were supported by sufficient numbers of safely recruited staff.” from the report
Training and healthcare
Staff had an induction, ongoing training and regular supervision. People were supported to attend healthcare and community services.
“People were supported to access healthcare and community services to meet their individual needs.” from the report
People involved
People were consulted about meetings, activities and changes to communal areas. Records showed that suggestions had led to changes.
“People were encouraged to be involved and engaged in the running of the home.” from the report
Medicines records and risk checks
seriousRisks linked to medicines were not always assessed, and medicine administration records had gaps. Staff did not always follow the home's medicines procedures, creating a safety risk.
“Procedures in place to support the proper and safe management of medicines were not always followed by staff.” from the report
Weak quality monitoring
seriousCare plan audits, medicines audits and spot checks were not carried out consistently. Identified problems were not always assigned, followed up or sustained.
“There was no systematic approach to auditing in the service meaning that concerns relating to safety and quality were not always identified and action taken to ensure improvements were made and sustained.” from the report
Duty of candour not understood
needs fixingThe registered manager and deputy manager were not aware of the duty of candour, and the provider did not have a policy covering it. The report said this was important for an open response when things went wrong.
“The registered manager and deputy manager were not aware of the duty of candour and they told us the provider did not have a policy about this.” from the report
Staff appraisals not in place
minorStaff received supervision and training, but there was no appraisal system at the time of inspection. The manager said this was being designed.
“However, an appraisal system was not in place.” from the report
Communication with outside professionals
needs fixingTwo external health and social care professionals said information sharing and attendance at meetings had not always been consistent. The provider was aware of this and was working on the relationship.
“They told us communication from the service was not always effective.” from the report
- 01How are medicine risks assessed for people who self-administer, and where are the risk reduction plans recorded?
- 02How do you check that every medicine given, refused or missed is recorded immediately and accurately?
- 03Who is responsible for completing care plan, medicines and spot-check audits, and how do you make sure actions are completed?
- 04What has changed since the inspection to make sure the duty of candour is understood and followed?
- 05How do you now share information and attend meetings with external health and social care professionals?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 30 January 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 34-36 Shaftesbury Road
3 rated inspections over 2 years: the service has held its Good rating throughout.
- September 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- December 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 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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47 live-in carers within about an hour of Portsmouth
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,240 a week. 38 can care for a couple. 10 years' experience on average.
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“He stayed with her throughout the pandemic, refusing to visit his own family, who lived nearby, to reduce the risk of infection.”
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