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CQC report explained · a residential care home, run by Jigsaw Creative Care

77 Russell Street

77 Russell Street, Reading, RG1 7XG

Requires improvementpublished 10 January 2024, 2 years ago

Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.

The five questions inspectors ask
Safe?
Requires improvement
People were at increased risk because fire safety checks and precautions were not up to date. Cleaning arrangements and some medicines records were also incomplete.
Effective?
Good
Care was based on people's needs, choices and goals. Staff had relevant training, and people were supported with food, healthcare and decision-making.
Caring?
Good
Inspectors observed respectful and compassionate support. Relatives said staff understood people well and respected their choices, privacy and dignity.
Responsive?
Good
Care plans were personalised and included communication needs, preferences and activities. People were supported to maintain relationships and take part in interests they enjoyed.
Well-led?
Requires improvement
Management systems and audits did not reliably identify or address risks. Records were not always accessible when the registered manager was absent.
The latest report, explained

What inspectors found, January 2024

Jigsaw Creative Care Limited - 77 Russell Street was rated Requires Improvement; inspectors found kind, personalised care but serious fire safety and management weaknesses.

This was an unannounced inspection on 20 and 22 October 2023. One inspector observed care, spoke with relatives and staff, and checked care plans, medicines records, recruitment files and management records.

The home was rated Good for Effective, Caring and Responsive. People were treated with dignity, supported to make choices, and helped to enjoy activities and community life. Care plans were individualised and staff knew people's needs well.

The home was rated Requires Improvement for Safe and Well-led. Inspectors found fire risks, gaps in cleaning arrangements, incomplete medicines records and audits that had not identified important problems. They found breaches of Regulation 12 and Regulation 17.

Some immediate actions were taken after concerns were raised. These included arranging fire safety checks, servicing fire extinguishers, covering radiators, improving cleaning records, recording medicine-room temperatures and refurbishing the garden. CQC requested an action plan and said it would monitor progress.

What inspectors praised
  • Kind and respectful support

    People were treated with dignity and compassion. Staff supported privacy, independence and personal choices.

    Relatives told us and we observed, staff respected people and treated them with dignity and compassion.from the report
  • Personalised care

    Care plans reflected people's needs, preferences, routines, communication and goals. Staff knew the people they supported well.

    Care plans were individualised and reflected people's current needs, preferences, and daily routines.from the report
  • Activities and community life

    People were supported to take part in activities suited to their interests and to socialise with others. Their wishes were respected if they did not want to join in.

    Examples included going to the cinema, attending discos, going to the park, and cycling.from the report
  • Positive communication

    Relatives were kept informed, and staff understood how people communicated. The management team was described as open during the inspection.

    Relatives we spoke with described a positive and close working relationship with the management team.from the report
What inspectors were concerned about
  • Fire safety

    serious

    Fire risk assessments had not been reviewed since 2019, extinguisher servicing was overdue and a fire door was propped open. Inspectors said this placed people at increased risk of harm.

    Risks relating to fire safety had not been adequately assessed and mitigated placing people at increased risk of harm.from the report
  • Weak management checks

    serious

    Audits had not identified problems with fire safety, infection control, radiators or medicines. This led to a breach of good governance requirements.

    Audits had failed to ensure fire safety arrangements were robust, placing people at increased risk of harm.from the report
  • Cleaning and infection control

    serious

    There was no cleaning schedule for much of the property or for bedrooms between respite stays. Inspectors also found dust, dirt and a bathroom without hand soap.

    There was no cleaning schedule for the rest of the property and for cleaning of rooms between respite stays.from the report
  • Medicines records

    needs fixing

    Some medicines records did not show allergy information or clear start and end dates. Medicine-room temperatures were not being recorded at the time of inspection.

    2 people's medicine administration records had blank start and end dates.from the report
  • Recruitment evidence

    needs fixing

    One of four staff files checked did not contain a reference from a previous role involving children or vulnerable adults. The provider was advised to strengthen recruitment checks.

    We recommend the provider ensure satisfactory evidence of conduct and verification for leaving previous roles working with children and vulnerable adults are reviewed during the recruitment process.from the report
Questions to ask them, based on this report
  1. 01What has been done to update the fire risk assessment and keep fire extinguishers and fire doors safe?
  2. 02How do you now check that bedrooms are cleaned between respite stays and that all areas of the home are cleaned regularly?
  3. 03How are medicine records checked for allergies, start and end dates, and correct storage temperatures?
  4. 04How will management audits identify and correct safety problems before they put people at risk?
  5. 05What system is now in place so staff can access care and training records when the registered manager is absent?

This began as a focused inspection of Safe and Well-led, but concerns about premises and care-file records led CQC to widen it to Effective, Caring and Responsive; the previous rating was Good in all areas. This explanation was written from the published report of 10 January 2024 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 77 Russell Street

3 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.

  1. January 2024Requires improvementcurrent ratingdown from Good
    Safe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read what inspectors found at 77 Russell Street

  2. October 2017Goodstayed Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    We are reading this report · the original is on cqc.org.uk

  3. October 2015Good
    Safe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read this report on cqc.org.uk

  4. October 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  5. June 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  6. April 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  7. January 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  8. January 2011

    Registered with the Care Quality Commission on 13 January 2011.

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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