CQC report explained · a residential care home
What the CQC found at Underhall Respite and Resource Centre
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always managed safely, including problems with stock counts, as-required medicine instructions and opening dates. Staff numbers, safeguarding arrangements and infection control were otherwise described positively.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its rating was carried over from the previous inspection.
- Caring?
- Good
- This question was not inspected during this focused inspection. The report nevertheless describes kind staff and positive relationships with people.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its rating was carried over from the previous inspection.
- Well-led?
- Requires improvement
- Audits did not reliably identify medicine problems or missing and outdated care-plan information. There was not enough recorded oversight of whether care records reflected people's current needs and risks.
What inspectors found, June 2022
Underhall Respite and Resource Centre was rated Requires Improvement; inspectors found kind care and enough staff, but serious medicines and management-record problems.
This was an unannounced focused inspection on 05 May 2022. Inspectors checked whether the home had acted on its previous improvement plan, looking only at Safe and Well-led. They spoke with four people, four relatives and seven staff, and reviewed care, medicines and management records.
People said they felt safe and listened to. There were enough staff, and staff were described as kind and patient. The home supported people to make choices and worked with health and social care professionals.
However, medicines were not always managed safely. Stock records did not match the medicines held, there were no clear instructions for some medicines given when needed, and opening dates were not recorded. Care plans and audits also did not reliably show current risks or identify problems.
The overall rating remains Requires Improvement, as it was at the previous inspection. The home breached regulations about safe care and treatment and good governance. The regulator asked for an action plan and said it would monitor progress.
Enough staff
Inspectors found enough staff to meet people's care and emotional needs. Staff responded quickly and spent time talking with people.
“There were enough staff at the home to meet the needs of people.” from the report
Kind support
People had positive relationships with staff and said they felt listened to. Staff were observed to be kind and caring.
“People had a good relationship with staff and the registered manager and told us they felt listened to.” from the report
People's involvement
People and staff had regular opportunities to give feedback. Inspectors saw that feedback had influenced decisions at the home.
“People had the opportunity to feed back into the running of the service.” from the report
Safer recruitment
The previous recruitment problem had improved. The provider obtained employment histories, references and background checks before staff started work.
“The provider followed safe recruitment practices.” from the report
Medicine safety
seriousMedicine stock records did not match the medicines held. Some medicines given when needed lacked clear instructions, and opening dates were missing.
“Medicines were not always managed safely. For example, there was no system in place to count stock carried over from the previous cycle of medicine.” from the report
Weak management checks
seriousAudits did not identify important problems with medicines and care plans. The home did not have enough recorded oversight of whether records were accurate and current.
“The provider's audits did not always effectively identify areas for improvement.” from the report
Incomplete risk records
needs fixingStaff understood people's risks, but the written care plans did not always record them clearly. It was also not always recorded when risk assessments had been reviewed.
“The registered manager and staff had a good understanding of people's known risks and how to support them safely. However written records did not always reflect this knowledge.” from the report
- 01How are medicine stock levels now checked, and what happens if the records do not match the medicines held?
- 02Are clear written protocols now in place for medicines given when needed?
- 03How do you record medicine opening dates and check expiry dates?
- 04How often is each person's care plan and risk assessment reviewed, and where is this recorded?
- 05What actions were included in the improvement plan sent to the regulator, and what progress has been made?
This was a focused inspection of Safe and Well-led only; the other key-question ratings were carried over from the previous inspection. This explanation was written from the published report of 29 June 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.
What inspectors found, April 2019
Requires Improvement; inspectors found kind, personalised care, but weaknesses in safety records, staff recruitment and management systems.
This was the first inspection. It was unannounced and took place over 26 and 27 February 2019. One inspector spoke with people, visitors, staff and social care professionals, observed care, and checked care, medicines, staff and management records.
People were treated with kindness and respect. Staff knew people well and provided personalised support. Food was well received, people were helped to access healthcare, and activities and visits supported their choices and relationships.
There were important gaps in safety and record keeping. Risk assessments and care plans did not always contain enough detail. Medicines records and storage needed improvement. Recruitment checks were not always complete, and some required notifications had not been sent to CQC.
The overall rating was Requires Improvement. Effective, Caring and Responsive were rated Good. Safe and Well-led were rated Requires Improvement. The provider was required to send an action plan, and CQC said it would continue to monitor the home.
Kind and personalised care
Staff knew people's backgrounds, interests and preferences. Inspectors saw many examples of support being adapted to individual people.
“People received support from a consistent staff team that knew and understood their needs and preferences well.” from the report
Respect and choice
People were involved in everyday decisions and staff supported privacy, dignity and independence. Staff made time to talk with people.
“During the inspection we observed staff took time to spend interacting with people.” from the report
Health and social care links
The home worked positively with GPs and other professionals. Staff supported people to attend appointments and shared concerns when needed.
“We received positive feedback from two social care professionals about how the service worked in partnership with them.” from the report
Activities and relationships
People took part in activities and trips out. The home supported contact with families and did not restrict visits.
“We saw people taking place in a range of activities during the inspection that were led by the staff-team or part-time activities co-ordinator.” from the report
Limited risk records
needs fixingStaff often understood and acted on risks, but this was not reliably recorded. There were no formal assessments for some risks, including malnutrition and skin integrity.
“The scope of formal, documented risk assessment was limited.” from the report
Medicines management
needs fixingSome medicines records did not explain missed doses. There were no written protocols for some medicines taken when needed, and storage temperatures were not monitored.
“Some improvements were required to ensure medicines were managed safely and according to good practice guidance.” from the report
Recruitment checks
seriousThree of four staff records did not have a full employment history. Three staff had started before a DBS check was received, and references were not always obtained or clearly recorded.
“Recruitment procedures were not always operated effectively to ensure required information about employees was obtained, and to help ensure staff were of suitable character.” from the report
Weak governance and records
seriousAudits did not identify some problems, and records did not always show decisions about care or actions taken to manage risks. This could make it harder to monitor the home if the manager was absent.
“The provider was not operating effective systems to assess, monitor and improve the quality and safety of the service.” from the report
Regulatory notifications and capacity
seriousThe provider had not sent required notifications about expected deaths. Before the inspection, the home had admitted more people than its registration allowed, although CQC decided not to take further action in that instance.
“The provider had not sent us notifications about expected deaths as required.” from the report
- 01What has been done to improve risk assessments for malnutrition, skin integrity, falls and other risks?
- 02How are medicines now stored, including controlled drugs, and how are storage temperatures checked?
- 03Are all staff now employed only after the required DBS, employment history and reference checks are complete?
- 04How do you check that care plans contain enough detail about each person's needs, independence, preferences and end of life wishes?
- 05What changes have been made to audits and records so that problems are identified and followed up?
This inspection covered the care home and people receiving personal care there, but the separate day service was outside the scope of the inspection. This explanation was written from the published report of 12 April 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 Underhall Respite and Resource Centre
2 rated inspections over 3 years: the service has held its Requires improvement rating throughout.
- June 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Underhall Respite and Resource Centre →
- April 2019Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Underhall Respite and Resource Centre →
- January 2018
Registered with the Care Quality Commission on 15 January 2018.
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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