CQC report explained · a residential care home
What the CQC found at Passmonds House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Inspectors were assured that the home was using PPE safely, providing testing, managing visits and admissions, and keeping its infection prevention and control policy up to date. The provider also said it had measures to manage COVID-19-related staffing pressures.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, February 2022
Inspected but not rated; inspectors found good infection control, safe visiting arrangements and measures to manage COVID-19 staffing pressures.
This was an announced, targeted inspection on 18 January 2022. The inspectors looked at infection prevention and control, and asked about staffing pressures linked to COVID-19.
The home appeared clean and uncluttered. Inspectors were assured that infection risks were being managed through cleaning, PPE, testing, social distancing, safe admissions and arrangements for visitors.
Visitors were allowed in line with guidance. People could keep in touch with relatives by video and telephone calls. Staff were fully vaccinated in line with government guidance.
The service was inspected but not rated. The report gives a view of infection control at this visit, rather than a full rating of the home’s overall quality.
Clean environment
The home was clean and uncluttered, with more frequent cleaning to reduce the risk of infection spreading.
“The home appeared clean and uncluttered, and an increased cleaning schedule was in place, to minimise the chance of cross infection.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for PPE, testing, social distancing, safe admissions and managing outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Contact with relatives
The home allowed visits in line with guidance and helped people stay in contact with relatives by telephone and video calls.
“People were supported to maintain regular contact with relatives through video calls and telephone calls.” from the report
Staff support for management
Staff spoke positively about the management and said they had no concerns.
“Staff spoke positively about the service and management and had no concerns.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you currently managing COVID-19 or other infection risks in the home?
- 02What cleaning schedule and outbreak arrangements are in place now?
- 03How do you manage visits when there is an infection risk?
- 04How are staffing pressures currently affecting residents’ care and activities?
- 05How can residents keep in regular contact with their relatives if visits are restricted?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; the service was inspected but not rated overall. 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, January 2019
Passmonds House was rated Good overall; inspectors found kind, responsive care and major improvements, but Safe was Requires Improvement because some harmful items were unsecured.
This was an unannounced inspection on 3 and 4 December 2018. Inspectors spoke with people living in the home, relatives and staff. They reviewed care records, staff files, medicines records, meetings and other management records. They also observed care.
The home had made major improvements since the previous inspection in March 2018. Infection control, cleanliness, staffing, training and the building had improved. The previous breaches had been addressed and the home was no longer in breach of regulations.
The main remaining safety issue was that some cleaning and grooming items, including a disposable razor and toiletries, were not properly secured. The home removed the items when inspectors raised this. Safe was rated Requires Improvement. Effective, Caring, Responsive and Well-led were rated Good, giving an overall rating of Good.
Major improvements
The home had addressed serious earlier concerns about infection control, cleanliness, the building and staffing. Inspectors found significant improvements and no continuing breaches.
“During this inspection, we found significant and major improvements had been made and the service was no longer in breach of the regulations.” from the report
Kind and personal care
Staff understood people's likes, dislikes and support needs. Inspectors saw people being treated with kindness and patience.
“People were treated with kindness and patience and had been encouraged to form their own friendship groups.” from the report
Detailed care plans
Care plans gave staff clear information about people's needs, choices, background and how they wanted support delivered.
“Care plans were comprehensive but easy to understand.” from the report
Safe medicines systems
Medicines were stored and managed by trained staff. The medicines records inspected were complete, with no unexplained gaps or omissions.
“We looked at four medicines administration records (MARs) and found they had been completed accurately.” from the report
Activities and social life
People took part in activities such as music, dancing, drawing, singing and performances. They were also encouraged to form friendships.
“I don't get bored – never. There is always something to watch or people to talk to” from the report
Unsafe items not secured
seriousInspectors found a disposable razor and toiletries in a communal bathroom that had not been properly secured. The items were removed after inspectors raised the issue.
“Some cleaning and grooming items which could be harmful if used incorrectly had not been properly secured.” from the report
Crowded shared lounges
minorThe main lounges were crowded, with little space between chairs and not always enough room for side tables. Some people had to balance drinks and snacks on their laps.
“This meant that when people had drinks and snacks some had to balance their cups and saucers on their laps.” from the report
- 01What checks are now in place to make sure razors, toiletries and other potentially harmful items are secured?
- 02How will you improve the crowded lounge areas and make sure people have safe places for drinks and snacks?
- 03How do you match staffing levels to the changing needs of people living here?
- 04How often are care plans reviewed, and how are changes in a person's health or wishes shared with staff?
- 05What activities would be available for someone with my relative's interests, mobility and communication needs?
This was an unannounced inspection of the home covering all five CQC questions, including care, accommodation, staffing, medicines and management, and it also checked improvements since the March 2018 inspection. This explanation was written from the published report of 16 January 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 Passmonds House
5 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- January 2019Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2018Requires improvementdown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2017Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2015Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- July 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 6 December 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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