CQC report explained · a residential care home
What the CQC found at Thetford Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found safe staffing, recruitment, safeguarding, medicines and infection control. They identified weaknesses in how some risks were recorded and in the detail of some mental capacity assessments.
- Effective?
- Good
- This key question was not inspected during this focused inspection. Its rating was carried over from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this focused inspection. Its rating was carried over from the previous inspection.
- Responsive?
- Good
- This key question was not inspected during this focused inspection. Its rating was carried over from the previous inspection.
- Well-led?
- Good
- Inspectors found good leadership, regular checks and staff who knew people well. They also found delays and gaps in communication with some relatives and healthcare professionals.
What inspectors found, August 2023
HF Trust - Thetford Road is rated Good; inspectors found safe, kind and person-centred care, with gaps in risk assessments, capacity records and communication.
The inspection took place on 14 June 2023. One inspector and an Expert by Experience visited the home, spoke with people, relatives, staff and healthcare professionals, and reviewed care records, medicines, recruitment files and management checks.
The home was rated Good overall, with Safe and Well-led also rated Good. Inspectors found enough staff, safe medicines practice, suitable safeguarding arrangements, good infection control and leaders who knew people's needs. People were supported to make choices, use the community and take part in activities.
There were some areas to improve. Risk assessments did not always explain how serious risks were or how they affected people. Some mental capacity assessments lacked information about how decisions had been reached. Communication with relatives and healthcare professionals was not always timely. This was a focused inspection, so the other three key question ratings were carried over from the previous inspection.
Safe medicines
Medicines were managed safely. Records were complete and staff had up-to-date medicines training.
“Medicines administration records were appropriately completed, and staff were up to date with the medicines training.” from the report
Choice and independence
People were supported to make day-to-day choices, access the community and take part in activities and work where they wished.
“People's independence was promoted to assist and improve the quality of their lives.” from the report
Staff knowledge
Staff knew people well and could recognise signs of anxiety or distress linked to changes in routine.
“Staff were knowledgeable about people's care and support needs and were able to recognise signs when people were feeling anxious about the changes in their routines.” from the report
Learning from incidents
Managers investigated incidents, shared lessons and took action when people's needs changed.
“Staff recognised incidents and reported them appropriately and managers investigated incidents and shared lessons learned.” from the report
Risk records
needs fixingRisk assessments did not always show how likely a risk was or its level of impact on the person. The provider said it would improve the electronic recording system.
“This meant that staff were not provided with information in relation to the impact the identified risks had on people.” from the report
Mental capacity records
needs fixingSome capacity assessments did not contain enough detail about how decisions had been reached. The provider was changing its assessment form.
“However, mental capacity assessments needed to be more specific including information on how the decisions were reached.” from the report
Communication
needs fixingSome healthcare professionals and relatives experienced delays or gaps in receiving information and updates about people's care.
“changes to people's care needs were not always communicated to them in a timely way.” from the report
- 01How have you improved risk assessments so they show the likelihood, level and impact of each identified risk?
- 02What changes have you made to mental capacity assessments, and can families see how decisions are reached?
- 03How will relatives receive regular updates, including when staff or key workers change?
- 04How quickly do you respond to healthcare professionals' requests for information?
- 05Which policies were out of date, and have they now been reviewed?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the previous inspection in 2019. This explanation was written from the published report of 17 August 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.
What inspectors found, April 2019
Rated Good; inspectors found safe, kind and personalised care, with all five areas rated Good.
Inspectors visited the home on 26 February 2019 and reviewed records at the provider’s office on 5 March 2019. They spoke with all eight people living there, staff and the manager, and checked care files, medicines, recruitment, training and quality checks.
People were found to be safe. Staff understood safeguarding, risks were assessed, medicines were recorded accurately and recruitment checks had been completed. Staff had suitable training and worked with health professionals to support people’s health.
Inspectors found that people were treated with dignity and respect, involved in their care and supported to make choices. Care plans were regularly reviewed, activities were shaped around people’s interests, and the home had systems for handling complaints and checking quality.
The overall rating was Good, with Good ratings for Safe, Effective, Caring, Responsive and Well-led. The home was rated Good at the previous inspection too, published on 14 September 2016.
Choice and independence
People were supported to make decisions, go out and take part in ordinary daily activities with as little restriction as possible.
“People had the independence and freedom to choose what they did and where they went, in safety with as little restriction to their liberty as possible.” from the report
Kind and respectful staff
Inspectors saw staff communicating sensitively and supporting people in a friendly, respectful way.
“Our observations showed that staff ensured people's privacy and dignity were respected at all times but especially when supporting them with personal care.” from the report
Personalised support
Care plans reflected people’s views, needs and preferences. Staff adapted support when people’s health or circumstances changed.
“Care plans were person centred and included people's views about how they wished to be supported.” from the report
Good partnership working
Staff worked with health and social care professionals to support hospital treatment, discharge and changing health needs.
“The staff team worked in partnership with people's social workers, and healthcare professionals including hospital staff, occupational and physio therapists” from the report
Safe medicines support
Medicines administration records were up to date and accurate, and people were given accessible information about their medicines.
“The MAR's we looked at were up to date and accurate. Medicines were stored securely.” from the report
Inspectors raised no specific concerns in this report.
- 01How would you support my relative to make their own decisions and maintain independence?
- 02How would you adapt their care if their health, communication or nutritional needs changed?
- 03How would you support my relative to understand and manage their medicines?
- 04How would you support my relative during a hospital admission or after discharge?
- 05How could my relative raise a concern, including if they found the usual complaints process difficult to use?
This inspection considered all five CQC questions, with the home visit on 26 February 2019 and records reviewed at the provider's office on 5 March 2019. This explanation was written from the published report of 13 April 2019 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 Thetford Road
3 rated inspections over 7 years: the service has held its Good rating throughout.
- August 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2019Goodstayed GoodSafe: GoodWell-led: Good
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- September 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 26 January 2011.
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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At least 100 live-in carers within about an hour of Kingston upon Thames
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 82 can care for a couple. 11 years' experience on average.
“Without his support we wouldn't have been able to navigate bringing and keeping Dad at home.”
“We cannot speak highly enough of the care that Angelique gave, and would recommend her to anyone else needing a live-in carer.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.