CQC report explained · a residential care home
What the CQC found at 3&4 Glebe Lane
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People said they felt safe. Staff understood safeguarding, risk assessments were in place and recruitment checks were completed. Inspectors recommended keeping night staffing under review as people's needs changed.
- Effective?
- Good
- People had suitable assessments, staff had relevant training and people received appropriate food and health care. Mental Capacity Act arrangements and authorisations were found to be in order and up to date.
- Caring?
- Good
- Staff were observed giving kind, patient and respectful support. They protected people's privacy and dignity and encouraged independence, choice and involvement in the local community.
- Responsive?
- Good
- Care plans covered people's physical, emotional, psychological and social needs and were reviewed when needs changed. People had individual activity planners, regular outings and support for communication and personal preferences.
- Well-led?
- Good
- The home had an experienced registered manager and regular quality monitoring. Records were organised and secure, and audits identified issues such as delayed medicine signatures and recording, which management was addressing.
What inspectors found, February 2019
Rated Good; inspectors found safe, kind and person-centred care, with night staffing and medicine records still being reviewed.
This was an unannounced inspection. The inspector spoke with people and staff, observed daily life, reviewed care plans, medicine records, staff files, staffing rotas, safety records and quality checks. All seven people living in the home were seen during the inspection.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were treated with kindness and dignity, supported to make choices and encouraged to be independent. Care plans were detailed and up to date, and people had access to health care, activities and outings.
There were two areas to keep watching. The provider was reviewing night staffing because people's needs in the bungalow had changed. Some staff had not signed medicine records promptly, although the provider was addressing this through its monitoring and staff processes. The overall Good rating was unchanged from the previous inspection in 2016.
Kind and respectful support
Inspectors saw staff providing patient care while protecting privacy, dignity and confidentiality. Staff knew people's histories, preferences and anxieties.
“We also observed kind and patient support being provided. Staff supported people in a respectful way.” from the report
Good risk management
Risk assessments and management plans gave staff clear guidance. The manager reviewed incidents and worked to reduce risks linked to falls, health problems and distress.
“Risk assessments and risk management plans supported people well.” from the report
Personalised care and activities
Care plans were detailed, person-centred and kept up to date. People were supported with their own interests, shopping, cooking, exercise and outings.
“The care assessments and plans were comprehensive, person centred and up to date.” from the report
Strong quality checks
The home had regular monitoring and audits covering medicines, care, safety, staffing and records. These checks were used to identify and address issues.
“These checks ensured that medicines administration, personal care delivery and recording of care practice were all audited and checked.” from the report
Night staffing
needs fixingStaffing levels at night were being changed because people in the bungalow had become more dependent. The inspector recommended keeping these arrangements under review.
“We recommend that night time arrangements be kept under review in the light of any changes.” from the report
Medicine signing records
needs fixingSome staff did not always sign medicine records promptly. The provider was addressing this through quality monitoring, supervision and disciplinary processes.
“some, but not all, staff did not always sign the records in a timely manner but this was being addressed by the provider” from the report
- 01What are the current night staffing arrangements in the bungalow, and what did the trial of a waking night staff member show?
- 02How do you now check that medicine records are signed promptly after medicines are given?
- 03What support can you provide for someone with complex physical or health needs, given that the home does not provide nursing care?
- 04How will the care plan be made easier for staff and residents to use as the format is reviewed?
- 05How are people and their families or advocates involved in decisions when someone cannot make a decision themselves?
This was an unannounced inspection covering all five key questions and the overall rating; the report summary says 9 November 2018, while the detailed inspection section says 9 January 2019. This explanation was written from the published report of 20 February 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.
What inspectors found, November 2016
West House - 3&4 Glebe Lane was rated Good; inspectors found safe, caring and well-organised support, with some plans for nutrition and building improvements.
This was an unannounced inspection over two days. Inspectors spoke with people living in the home, relatives, staff and health professionals. They observed care, checked all eight care files, medicines, staff records, policies, buildings, food and equipment.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found suitable staffing, safe medicines systems, trained staff, detailed person-centred care plans and respectful support.
People were supported to make choices, stay as independent as possible and take part in activities, outings, holidays and community life. Inspectors noted that some parts of the buildings looked tired, nutrition plans were still being developed for some people, and night-time arrangements were being kept under review.
Safe staffing and medicines
Staffing was adjusted when people's needs changed. Medicines were checked by two people during the day and audited regularly.
“Medicines were suitably managed with staff receiving training and checks on competence.” from the report
Kind and respectful care
Staff explained things patiently, protected people's dignity and encouraged them to do as much as possible for themselves.
“Staff were kind, polite and considerate. They treated people with respect.” from the report
Detailed care planning
Inspectors found detailed care, health and person-centred plans covering people's needs, wishes, strengths, communication and preferred activities.
“Each person in the home had a detailed care plan and a health care plan.” from the report
Meaningful lives
People took part in activities, outings, holidays, meals out, shopping and community events. They were also involved in cooking and running their homes.
“We judged that people in this service had a well rounded life.” from the report
Strong management checks
The home had regular quality checks covering care plans, the environment, food safety, medicines, staffing and people's money.
“West House had a suitable quality monitoring system in place that sat alongside their policies and procedures.” from the report
Some areas looked tired
minorAlthough both buildings were warm, comfortable and homely, inspectors noted that some areas needed updating. The manager described plans to upgrade the environment.
“Some parts of the buildings looked a little tired but the registered manager told us of plans to continually upgrade the environment.” from the report
Nutrition plans still developing
needs fixingSome people needed help to maintain their weight. Inspectors found nutritional planning in place, but the team wanted to develop it further.
“Nutritional planning was in place as part of care planning but the team wanted to develop these further.” from the report
Night arrangements under review
minorOne person slept in each house at night. Staff said this worked well, but the manager was reviewing the arrangements as people's needs changed.
“We did discuss this with the registered manager and she said that, given people's needs were changing, she was keeping the night time arrangements under review.” from the report
- 01What progress has been made with the planned upgrades to the parts of the buildings that looked tired?
- 02How do you monitor people's weight and nutrition, and what further development was planned for nutritional care?
- 03How are night-time staffing arrangements reviewed when people's needs change?
- 04How often are medicines checked now, and what extra checks were introduced after the previous medicines management issue?
- 05How will my relative be involved in keeping their person-centred plan and care plan up to date?
This was an unannounced overall inspection covering all five questions, including observations, discussions, records, medicines, staffing, buildings, food and equipment. This explanation was written from the published report of 4 November 2016 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 3&4 Glebe Lane
2 rated inspections over 2 years: the service has held its Good rating throughout.
- February 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 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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