Our Action Plan following CQC Inspection 08/26

Our Action Plan following the CQC inspection in August 2026. 

As a Home we have worked very hard addressing the concerns raised by the CQC.

Safeguarding Residents.

The management of the Home have put in place a qualified Independent Safeguarding Officer (ISO) to support the management and staff when risk assessing any incident or accident with the potential to be a safeguarding matter.

We wish to reassure everyone that the ISO has risk assessed the five members of staff whose DBS showed a caution or conviction and found them to be either a low or trivial risk as these were both historic (none later than 2014) and were not part of a pattern of offences. The Home will continue to carry out an Enhanced DBS check for all prospective employees and will ensure a formal risk assessment is completed by the ISO before employment commences where there is a caution or conviction. 

We are a single Home, family run organisation. Possibly due to this, we have a staff team that consists of long standing staff members, with a significant number who are related to each other. We understand the concern that this could cause cliques. The management have redesigned the staff rota and duty allocation sheets based around a colour coded system that identifies family relationships. This new arrangement ensures family members do not work together directly. It also results in the manager of the Home allocating duties, which together with regular checks, ensures tasks are shared out in a fair and equal way. 

The CQC identified the stair gates as not being adequate in that clients at risk of falling could bypass a nurse call pressure mat and gain access to the stairs too quickly. As a consequence, the management of the Home have replaced both gates on the front stairs and installed a number of magnetic keypad locks, ensuring that all vulnerable residents are now unable to gain access to stairs leading from the first floor. Please note that no one has fallen down the stairs but we do understand action was required.

The CQC were concerned that some staff felt unable to speak up about concerns. As a consequence, the management of the Home, together with the suggestion box already in place, have now created a QR Code and also regularly circulates a link to staff enabling everyone to be able to anonymously report any concerns and suggestions via an email to the management of the Home. We will of course continue our open door policy for anyone who wishes to raise a concern and our aim is that these additional measures will empower all staff, relatives and representatives to speak up and/or whistleblow, whilst retaining their anonymity. 

Good Governance.

The management of the Home have expanded resident care plans and risk assessments to include more detailed information around identifying symptoms relating to relevant conditions & illnesses and also what action to take when detecting these.

The management of the Home has also improved the Home’s auditing system to develop the learning culture within the organisation, providing opportunity for residents, staff & representatives to make suggestions and enable management to record these and act upon them. The improved Good Governance Audit brings together all these suggestions and actions to identify themes and trends and show how actions taken have improved the quality of the service provided.

The management of the Home is confident and wishes to reassure everyone that the changes made will improve care in a way that makes it more consistent, personal and reactive. For staff, we believe duties will be allocated in a fairer way and they will feel more confident, whether it be in identifying when someone is unwell, knowing what to do and feeling comfortable raising concerns and making suggestions.