CQC report explained · a nursing home
What the CQC found at 367 Thornaby Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed, medicines were managed safely, infection control procedures were effective and staffing was stable. Staff recruitment included checks designed to reduce the risk of unsuitable people being employed.
- Effective?
- Good
- Support was based on people's needs and preferences. Staff had regular training, supervision and appraisals, and worked with other professionals to support people's health.
- Caring?
- Good
- Staff were caring and kind, and people were treated with dignity and respect. Staff understood people's individual ways of communicating and supported their independence.
- Responsive?
- Good
- People received personalised support and were involved, with relatives, in care planning. Inspectors recommended improving accessible written information, and noted that some care plans were clinical and lacked people's voice.
- Well-led?
- Good
- The home had a caring and empowering culture. The manager and provider used quality checks, sought feedback and made plans to address issues.
What inspectors found, February 2022
367 Thornaby Road is rated Good; inspectors found kind, safe and personalised care, with some written information needing to be more accessible.
This was an unannounced planned inspection. Inspectors visited on 7 December 2021, 16 December 2021, 5 January 2022 and 11 January 2022. They observed people and staff, spoke with relatives, an external professional and five staff, and checked care records and other documents.
The home was supporting four people with learning disabilities and could support up to five. All five areas were rated Good: safe, effective, caring, responsive and well-led. Inspectors found that people were protected from abuse, received medicines safely, and were supported by trained staff who knew them well.
People received kind and personalised care. Staff supported people's choices, health, relationships and activities. The home had effective checks on quality and safety, and relatives said communication with the home was open.
Inspectors recommended improvements to the way written information was made accessible. They also found that some communal areas and care plans felt clinical and did not show enough of people's individuality.
Kind and respectful care
Inspectors saw many caring interactions. Relatives described the staff team as dedicated, caring, polite and respectful.
“Staff were caring and kind, and people were well-treated.” from the report
Personalised support
Support reflected people's assessed needs, preferences and choices. People were helped to enjoy their interests and maintain important relationships.
“People received personalised support based on their assessed needs and preferences.” from the report
Safe medicines and risk management
Risks were assessed and managed, and medicines were given safely. Staff were trained and confident in medicines management.
“Medicines were managed safely, and people received these when they were needed.” from the report
Staff knew people well
Staff understood people's communication, including facial expressions and sounds, and used this to help people express their views.
“Staff knew people well and were able to help them express their views and decisions.” from the report
Quality checks and feedback
The manager and provider monitored the quality of the home, acted on issues and regularly asked relatives and staff for their views.
“The manager and provider carried out a number of quality assurance checks to monitor and improve standards.” from the report
Written information was not always accessible
minorAlthough staff knew how to communicate with people, support plans and other written information were not always presented in ways people could understand. Inspectors made a recommendation for improvement.
“However, support plans and other written information was not always made available in ways that might be accessible to them.” from the report
Some areas and care plans lacked personalisation
minorSome communal areas were described as clinical. Inspectors also said some care plans did not use people's own voice, and the manager said these would be reviewed.
“Communal areas were adapted to meet people's support needs, but were sometimes clinical and lacked personalisation.” from the report
- 01How are you acting on the recommendation about making support plans and other written information accessible?
- 02How will you make the communal areas feel less clinical and more personal?
- 03How are you changing care plans so they reflect each person's own voice?
- 04How do staff recognise and record each person's non-verbal communication and choices?
- 05How will relatives be involved in reviewing these improvements?
This was an unannounced planned inspection covering all five CQC questions, including the accommodation and care provided; people could not communicate verbally, so inspectors relied on observation, records and discussions with relatives, staff and an external professional. This explanation was written from the published report of 5 February 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, August 2018
367 Thornaby Road was rated Good; inspectors found kind, safe and personalised care, with some records needing improvement.
The inspection was unannounced and took place over four visits in July 2018. Inspectors observed care, spoke with relatives and staff, reviewed care and medicine records, and checked policies and other records.
The home supported five people with learning disabilities and autism. Inspectors found that people were safe, treated with dignity and respect, supported to make choices, and helped to take part in activities and community life.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The home had also been rated Good at its previous inspection in March 2016, so the overall rating remained Good.
Kind and respectful support
Inspectors saw staff offering thoughtful support based on people's individual choices and preferences. People were treated with dignity in private and communal areas.
“Throughout the inspection we saw numerous examples of kind and caring support being delivered.” from the report
Personalised communication
Staff understood how people communicated without speech and used this knowledge to help them express choices and take part in decisions.
“We saw staff following this during our visit which meant the person could communicate what they would like to do and were involved in making decisions and choices for themselves.” from the report
Safe staffing and medicines
Staffing levels were based on people's assessed needs, and medicines were stored and administered safely. Recruitment checks were also in place.
“The provider ensured enough staff were in place to support people safely.” from the report
Activities and independence
People were supported to attend day services, enjoy hobbies, visit places in the community and plan holidays. Staff encouraged people to do as much as possible for themselves.
“People were supported to be as independent and live as full a life as possible.” from the report
Quality oversight
The manager carried out checks on areas such as care plans, the environment and infection control. The report says action was taken when checks found problems.
“Records showed that where issues were identified remedial action was taken.” from the report
Fire safety records
needs fixingFire drills and discussions about fire safety were not always recorded. The manager said recording would be improved.
“However, we saw that fire drills and discussions of fire safety were not always recorded.” from the report
Supervision records
needs fixingStaff supervision records were not consistently stored in one place. Some were kept at the home and others were in a secure online system the manager could not access.
“We did see that meeting records were not consistently stored, with some kept in a folder at the service and others stored online in a secure system that the registered manager did not have access to.” from the report
- 01How are fire drills and fire safety discussions recorded now, and when was the last drill?
- 02Are all staff supervision records now kept in one place that the registered manager can access?
- 03How are people's communication methods recorded and checked when their needs or preferences change?
- 04How will the home support people with end of life care if this is needed?
- 05How are relatives' feedback and complaints reviewed, and what changes have been made as a result?
This was an unannounced inspection covering all five CQC questions, with visits, discussions, record checks and feedback from relatives, staff and other professionals. This explanation was written from the published report of 18 August 2018 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 367 Thornaby Road
4 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- February 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- June 2010
Registered with the Care Quality Commission on 17 June 2010.
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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