CQC report explained · a nursing home
What the CQC found at Frethey House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found mostly effective infection control arrangements, including testing, protective equipment, hygiene measures and outbreak procedures. They found gaps in recording vaccination information for visiting professionals and COVID-19 test information for two recent admissions.
- Effective?
- Good
- This area was not assessed in this targeted inspection.
- Caring?
- Good
- This area was not assessed in this targeted inspection.
- Responsive?
- Requires improvement
- This area was not assessed in this targeted inspection.
- Well-led?
- Good
- This area was not assessed in this targeted inspection.
What inspectors found, March 2022
Targeted infection control inspection; the home was not rated overall, and inspectors found mostly safe COVID-19 arrangements but gaps in recording some checks.
Inspectors visited the home without notice on 10 February 2022. This was a targeted inspection focused on infection prevention and control, including COVID-19 safety and staffing pressures.
People and visitors said they felt safe and could visit regularly. Inspectors found supplies of protective equipment, testing arrangements, hand hygiene measures and processes for managing outbreaks. Staff were generally using protective equipment correctly.
Some records needed improvement. The home had not recorded COVID-19 vaccination information for visiting professionals and contractors. COVID-19 test information was also not confirmed for the two most recently admitted people, although precautions had been used and new recording systems were put in place after the inspection.
The service was inspected but not rated. This report does not give an overall Good or Requires Improvement rating, and it does not assess all five areas of care.
People felt safe
People told inspectors they felt safe and spoke positively about staff.
“Staff always make sure I am ok. The staff here are lovely” from the report
Safe visiting
Visitors could visit regularly, with testing, protective equipment and hand sanitiser available.
“The provider was facilitating safe visiting in line with government guidance.” from the report
Protective equipment
The home had a good supply of protective equipment and inspectors were assured it was being used safely.
“We were assured that the provider was using PPE effectively and safely.” from the report
Staffing cover
The home had enough staff to provide continuity of care, with regular agency staff used during absences.
“There were sufficient staff to provide continuity of care and support.” from the report
Outbreak arrangements
Inspectors were assured that the home could prevent or manage infection outbreaks and that its infection control policy was up to date.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Visitor vaccination records
needs fixingVaccination information for visiting professionals and contractors was being checked but had not been recorded. The manager sent new records after the inspection.
“COVID-19 vaccination passports were being reviewed for visiting professionals and contractors, although not recorded.” from the report
Admission test records
needs fixingCOVID-19 test results could not be confirmed for the two most recent admissions. The home had used isolation precautions and later sent new records to improve this process.
“COVID 19 tests could not be confirmed for the two most recently admitted people.” from the report
Mask positioning
minorOne staff member needed reminding about the position of their mask during the inspection.
“One member of staff was reminded about the position of their mask.” from the report
- 01How are COVID-19 vaccination checks for visiting professionals and contractors now recorded and reviewed?
- 02How do you confirm and record the COVID-19 status of every new admission?
- 03How do you make sure all staff wear protective equipment correctly throughout their shifts?
- 04What were the staffing pressures at the time of the inspection, and has recruitment of care and domestic staff been completed?
- 05How will you show us the home's ratings and findings for caring, effective, responsive and well-led care, which this inspection did not assess?
This was an unannounced targeted inspection of infection prevention and control and staffing pressures; the service was inspected but not rated and the other care areas were not assessed. This explanation was written from the published report of 4 March 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, October 2020
Rated Good; inspectors found safer, kinder and better-organised care after the previous Requires improvement rating.
This was an announced focused inspection on 3 September 2020. Inspectors checked Safe, Effective, Caring and Well-led. They visited the home, spoke with people, relatives and staff, observed care, and reviewed care records, medicines records, staff files and quality checks.
The home was rated Good in all four areas inspected. Inspectors found improved staffing, more detailed care plans, safer medicines practice, better infection control and kind support. People and relatives described improvements in staffing, teamwork and the atmosphere.
The previous inspection had rated the service Requires improvement. The report says all five previous breaches had been addressed. Inspectors still identified a need for closer attention to one person's snacks and supplements, and agreed to follow up a request for more frequent baths.
More consistent staffing
The home had recruited additional staff and no longer needed agency staff. People had regular staff they knew and trusted.
“This meant people were always cared for by staff they knew and trusted.” from the report
Safer medicines
Medicines were given safely and on time by trained staff whose competence had been checked. Storage, ordering and audits were also in place.
“Improvements in medicines management had been made and people received their prescribed medicines safely and on time” from the report
Kind and respectful care
People were treated with kindness, dignity and respect. Staff encouraged independence and gave supportive help at mealtimes.
“People were supported by staff who were kind and respectful towards them and encouraged them to be as independent as possible.” from the report
Improved management
Inspectors found better organisation, communication and oversight. Quality checks were being used to identify problems and make improvements.
“Effective quality assurance and monitoring systems had been embedded and were used to identify shortfalls and drive improvements.” from the report
Infection control
Inspectors were assured that the home had arrangements for preventing and managing infections, including use of protective equipment and testing.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Nutrition monitoring
needs fixingInspectors felt one person needed closer monitoring to make sure they were offered snacks and supplements more often. The manager said this would be followed up.
“We identified one person where we thought further vigilance was needed to ensure they were offered more regular snacks and supplements” from the report
Bathing preference
minorOne person's request for more frequent baths had not yet been resolved during the inspection. The manager agreed to follow it up.
“We discussed one person's wish to be offered a bath more frequently with the registered manager, which they agreed to follow up.” from the report
- 01How do you now make sure each person receives enough snacks, supplements, food and drink?
- 02How are bathing preferences recorded and checked, including requests for more frequent baths?
- 03Have the improved staffing levels and regular staff team continued since the September 2020 inspection?
- 04How often are medicines, care plans and risk assessments audited, and how are any problems acted on?
- 05What was the rating for Responsive at the previous comprehensive inspection, and what has changed since then?
This was a focused inspection of Safe, Effective, Caring and Well-led only; Responsive was not assessed and its previous rating carried over. This explanation was written from the published report of 8 October 2020 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 Frethey House
4 rated inspections over 6 years: the service has held its Good rating throughout.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- October 2020Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- September 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementWell-led: Requires improvement
- March 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Registered with the Care Quality Commission on 4 July 2013.
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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