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CQC report explained · a residential care home, run by City of York Council

Flaxman Avenue

77 Flaxman Avenue, York, YO10 3TW

Goodpublished 25 November 2023, 2 years ago

Rated Good: inspectors found the service performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
People received their medicines safely and there were enough staff to meet their needs. However, some risk assessments were too general and did not always show how individual risks would be reduced.
Effective?
Good
Support plans reflected people's needs, choices and preferences, and staff worked with relatives and professionals. Some staff had not completed training relevant to the people they supported.
Caring?
Good
Staff were described as caring, patient and attentive. People were treated with dignity and respect and supported to communicate and make choices.
Responsive?
Good
Care and activities were personalised. Staff used people's preferred communication methods and worked closely with relatives during stays and transitions.
Well-led?
Requires improvement
The home had a positive culture, but management systems were inconsistent. Some records were out of date, audits did not always identify problems and formal team meetings had not taken place regularly.
The latest report, explained

What inspectors found, November 2023

Rated Good overall; inspectors found kind, personalised care, but leadership and governance required improvement.

This was the first inspection since the home registered with the CQC. One inspector visited on 25 October 2023 and inspection activity continued until 27 October. The inspector observed care, spoke with relatives and staff, and checked care files, medicines records and management documents.

People were supported to make choices and be as independent as possible. Inspectors found safe medicines practice, enough staff to meet people's needs, kind and respectful care, personalised support and good communication with relatives.

The main weaknesses were in leadership and record-keeping. Some risk assessments did not reflect individual risks, some staff training was incomplete, and some records and audits were not up to date or effective. The CQC rated the home Good overall, with Safe, Effective, Caring and Responsive rated Good, but Well-led rated Requires Improvement.

What inspectors praised

  • Choice and independence

    People were supported to make choices, have control over their lives and develop their independence. Staff used the least restrictive approach and followed best-interest processes where needed.

    “People were supported in a service which promoted choice, control and independence.” from the report

  • Safe medicines

    Inspectors found that medicines were given as prescribed. The home had systems for recording medicines entering and leaving the service.

    “Medicines were administered safely. People received their medicines as prescribed.” from the report

  • Kind and respectful care

    Staff knew people well and built trusting relationships. People were treated with dignity, privacy and respect.

    “Staff were passionate about the people they supported. Staff were caring, patient and attentive.” from the report

  • Personalised communication

    Staff understood how people communicated and used suitable approaches, including visual cards. Support plans explained people's choices and communication needs.

    “People's communication needs were met. Staff knew how people communicated and were observed responding to people appropriately.” from the report
What inspectors were concerned about

  • Risk records were too general

    needs fixing

    Most risk assessments did not always reflect people's specific needs or explain the controls needed to reduce risks. The CQC recommended a review of the risk assessment process.

    “However, most risks assessments were generalised and did not always consider the individual's specific needs or show control measures to reduce these particular risks.” from the report

  • Some training was incomplete

    needs fixing

    Inspectors found that staff had not always completed training relevant to the people they supported. Team leaders managed the skill mix on shifts.

    “However, we identified staff had not always completed training relevant to the needs of the people they supported.” from the report

  • Weaknesses in governance and records

    needs fixing

    Some agency induction records and parts of people's files contained out-of-date information. Audits had not identified every issue, and the CQC recommended improving governance systems.

    “Effective governance systems were not always in place. Not all documentation relating to the management of the service had been updated or reviewed.” from the report
Questions to ask them, based on this report
  1. 01How have you updated individual risk assessments so they clearly describe each person's current risks and control measures?
  2. 02Which staff training relevant to people's needs was incomplete at the inspection, and has it now been completed?
  3. 03How do you check that care files, agency induction records and other documents contain current information?
  4. 04What changes have you made to audits so they identify errors and confusing records?
  5. 05How will you provide regular team meetings and formal staff support while you recruit permanent staff?

This was the first comprehensive inspection since the home registered, covering all five CQC questions and both the premises and care provided. This explanation was written from the published report of 25 November 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.

The story over the years

Every inspection of Flaxman Avenue

3 rated inspections over 8 years: the service has held its Good rating throughout.

  1. November 2023Goodcurrent ratingstayed Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read what inspectors found at Flaxman Avenue →

  2. December 2017Goodstayed Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
  3. November 2015Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
  4. September 2022

    Registered with the Care Quality Commission on 21 September 2022.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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