CQC report explained · a residential care home
What the CQC found at No 11&12 Third Row
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from harm and avoidable risks. Inspectors found safe medicines management, safeguarding procedures, infection control and appropriate staff recruitment checks.
- Effective?
- Good
- This area was not inspected during this focused inspection. The previous rating was used when calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this focused inspection. The previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This area was not inspected during this focused inspection. The previous rating was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Management and leadership were not always consistent. Notifications to CQC were missed, and records did not always show what action had been taken after audits.
What inspectors found, January 2024
Rated Good overall, but inspectors found well-led arrangements required improvement and a breach over missed notifications.
This was a focused inspection on 16 October 2023. The inspector looked only at whether the home was safe and well-led. They spoke with staff, relatives and a care manager, and reviewed records and information from other sources.
The home was rated Good for safe care. Inspectors found enough staff overall, safe medicines practice, safeguarding arrangements, infection control and suitable recruitment checks. People were supported to make choices, stay in contact with family and use the community.
The home was rated Requires Improvement for being well-led. The provider had not always notified CQC about events it was legally required to report, and records did not always show what action followed audits. The overall Good rating includes ratings from areas not inspected at this visit.
People were known well
Staff understood people's non-verbal communication, preferences and individual needs. Relatives said staff could recognise distress and identify what people needed.
“Staff had worked with the individuals for a considerable time and knew them extremely well, including their likes and dislikes and personal preferences.” from the report
Safe medicines practice
Inspectors found that medicines were given as prescribed and records were complete and current.
“Medicine records were complete and up to date, including 'as an when required' medicines and homely remedies.” from the report
A homely atmosphere
Relatives described the home as safe and family-like. People were supported to keep regular contact with relatives and to go out if they wished.
“Relatives told us the atmosphere at the service was homely and safe.” from the report
Staff support
Staff said the registered manager was usually available and they could raise concerns or ask for help.
“They are available all the time. You don't feel as if you are on your own.” from the report
Weekend staffing
needs fixingThere was only one staff member at weekends and during the night. CQC recommended reviewing weekend staffing so people could access the community with support.
“We recommend the provider review weekend staffing levels to ensure people can access the community with support if they so wish.” from the report
Risk records
needs fixingPeople were cared for safely, but records did not always clearly identify the specific risks or how those risks were being reduced.
“It was not always possible from documentation to identify the specific risk related to care and how this was mitigated, although people were cared for safely.” from the report
Missed notifications
seriousThe provider had not always told CQC about events it was legally required to report. The registered manager later made the required notifications.
“We found the provider had not always notified CQC of instances that they are legally required to do so.” from the report
Audit follow-up
needs fixingThe home had checks and audits, but records did not always show what action had been taken in response to them.
“It was not always clear what actions had been taken in response to audits.” from the report
- 01How many staff will be on duty at weekends, and how will this affect community activities?
- 02How do you record and review the specific risks for each person?
- 03What changes have you made to show clearly what action follows each audit?
- 04What events must be notified to CQC, and how do you make sure notifications are sent on time?
- 05How will you continue to understand the needs of people who communicate non-verbally?
This was a focused inspection of Safe and Well-led only; the other ratings carry over from the previous inspection and were used to calculate the overall rating. This explanation was written from the published report of 4 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.
What inspectors found, August 2018
No 11&12 Third Row was rated Good; inspectors found kind, safe and personalised care, with minor records issues around medicines and recruitment.
Inspectors visited the home on 22 June 2018. The visit was announced because the home is small. They spoke with people, relatives, care staff, managers and care professionals. They also looked at care plans, a recruitment file and records about quality and safety.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found suitable staffing, safe medicine systems, regular checks, good support with health and nutrition, kind staff and care plans that reflected people's needs and preferences.
The provider had improved the issues found at the previous inspection in January 2017. DoLS applications had been made correctly and checks on quality and safety were stronger. Inspectors did identify that instructions for some medicines were not detailed enough and that one recruitment file had a gap.
Kind and respectful staff
Inspectors saw caring interactions and found that staff understood people's communication, needs and preferences.
“We observed kind and caring interactions between people and staff and saw the needs of people with communication difficulties were responded to by caring staff who knew them well.” from the report
Personalised care
Care plans covered people's physical, psychological and social needs. Staff supported people with their routines, choices, independence and interests.
“Person centred care plans relating to people's physical, psychological and social needs were in place.” from the report
Improved oversight
The home had strengthened its checks on care quality and safety since the previous inspection. Staff supervision and meetings were also taking place more regularly.
“At this inspection, we found this had improved and effective systems were in place.” from the report
Good health support
People were supported with health appointments, nutrition and specialist advice when needed. The home also made arrangements to reduce the stress of some appointments.
“People had access to healthcare services including an annual health check.” from the report
As-needed medicine instructions
needs fixingInstructions for some medicines given only when needed did not clearly explain the circumstances or signs for giving them. The provider said a new protocol was put in place immediately after the inspection.
“Instructions for medicines to be given as and when required were not always sufficiently detailed.” from the report
Recruitment record gap
minorInspectors found one gap in a recruitment file. The manager said staff records would be added to routine audits to check that files contained the correct information.
“We found one gap in the recruitment file and discussed this with the registered manager.” from the report
- 01What does the new protocol say about when each as-needed medicine should be given, and how is this checked?
- 02How do you now audit recruitment files to make sure all required information is present?
- 03How do you track DoLS applications and renewal dates for each person?
- 04How are care plans reviewed when a person's communication, health needs or preferences change?
- 05How do you make sure activities continue to match each person's interests and daily routine?
This was an announced inspection covering all five CQC questions, the premises, the care provided and the overall service rating. This explanation was written from the published report of 23 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 No 11&12 Third Row
5 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- January 2024Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- March 2017Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2016Goodup from Requires improvementSafe: GoodWell-led: Good
- November 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 February 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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Most charge £950 to £1,190 a week. 20 can care for a couple. 11 years' experience on average.
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