CQC report explained · a nursing home
What the CQC found at Thalassa Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risk records were not clear or complete. Inspectors found an absent plan for a person with severe contractures and records that did not always show planned repositioning had taken place.
- Effective?
- Good
- People received suitable food and drink support, staff were trained, and healthcare was arranged when needed. However, some consent forms and mental capacity records were not consistently correct.
- Caring?
- Good
- People and relatives described staff as kind and understanding. Inspectors observed people being treated with dignity, respect and compassion.
- Responsive?
- Requires improvement
- People's changing needs were usually acted on, but activity provision was limited and care plans needed more personal detail about people's preferences and needs.
- Well-led?
- Good
- Management was open and approachable, and staff felt supported. Quality checks were in place, although some care plan audits had not identified unclear risk information.
What inspectors found, June 2019
Rated Requires Improvement; inspectors found kind, safe care in many areas, but care records and activities needed improvement.
This was an unannounced inspection on 03 June 2019 and 06 June 2019. Inspectors spoke with people living in the home, relatives, staff and managers. They reviewed care records, medicines records, accident and complaint records, audits and quality checks.
People generally felt safe and listened to. Staff were kind and respectful, staffing levels were enough, medicines were given as prescribed, and the home was clean. Inspectors also found good training, support with food and drink, access to healthcare and open management.
The overall rating was Requires Improvement. Safe and Responsive were rated Requires Improvement because some risk and care records were unclear or inaccurate, and activity provision was limited. Effective, Caring and Well-led were rated Good. The previous overall rating was Good in 2016.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw warm, respectful interactions and people appeared comfortable with staff.
“Our observations of staff interactions with people showed that people were treated with kindness, compassion, dignity and respect;” from the report
Enough staff
Inspectors found enough staff to meet people's needs, and staff responded promptly to requests for help.
“There were sufficient staff to meet people's needs.” from the report
Medicines and infection control
Medicines were obtained, stored, given and recorded safely. The home was clean, and staff used suitable protective equipment.
“Medicine administration records confirmed that people had received their medicines as prescribed.” from the report
Open management
People, relatives and staff felt able to raise concerns with the manager. The home had audits, feedback surveys and an action plan for improvements.
“The registered manager demonstrated an open and transparent approach to their role.” from the report
Unclear risk records
seriousSome records did not give clear guidance about people's risks or show that planned care had been provided. This could increase the risk of unsafe care, particularly for people needing repositioning or with changing dietary needs.
“Some aspects of the service were not always safe because records about risks for people were not always clear.” from the report
Limited activities
needs fixingInspectors saw very little activity that people wanted to join during the inspection. Activity staff said some activities were difficult to organise because people needed help to take part.
“We observed very little in terms of activity provision that people wanted to engage in throughout the inspection.” from the report
Care plans needed more personal detail
needs fixingCare plans did not always include enough information about people's likes, dislikes, preferences and needs. The home was asked to seek guidance about providing meaningful activities.
“The registered manager was aware of the need to further develop care plans to ensure that they contained person centred detail including people's needs, likes, dislikes and preferences.” from the report
Consent records
needs fixingSome relatives signed consent forms when this was not needed or when they did not have legal authority. People's mental capacity assessments were also not recorded consistently.
“However, at times consent forms had been signed by people's relatives when this either wasn't required or they did not have the legal authority to do so.” from the report
- 01What has changed in care plan and risk record checks since this inspection?
- 02How do you make sure repositioning, dietary support and other planned care are recorded accurately each day?
- 03What activities are now available, and how are residents involved in choosing them?
- 04How do you check that consent forms are signed by the right person and that mental capacity assessments are recorded?
- 05What action was taken to improve the environment and signage for people living with dementia?
This was an unannounced inspection covering all five CQC questions, including the premises and the care provided. This explanation was written from the published report of 25 June 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.
What inspectors found, October 2016
Thalassa Nursing Home was rated Good; inspectors found safe, kind and well-organised care, with some records and medicines processes needing attention.
Inspectors made an unannounced visit on 29 September 2016. They spoke with people living in the home, relatives, staff and health and social care professionals. They also observed care and checked care plans, medicines records, staff files, complaints and quality checks.
All five areas were rated Good: safe, effective, caring, responsive and well-led. Inspectors found enough staff, suitable recruitment checks, safe medicine management, good support with food and decisions, and staff who treated people with kindness and respect.
There were some areas to improve. Not all care plans were updated promptly, some older records had not been archived, and audit action plans were not always clearly recorded. The home was also advised to seek further advice about disposing of small amounts of controlled medicines.
Enough staff
Inspectors found consistent staffing levels and said people received prompt, unhurried support. The home only occasionally used agency care staff for absences and holidays.
“There were sufficient staff available to meet people's needs.” from the report
Kind and respectful care
People and relatives spoke highly of staff. Inspectors saw staff taking time to listen, offer choices and protect people's dignity.
“The atmosphere in the home was warm, calm and very friendly.” from the report
Good understanding of risks
Staff knew people's health and safety risks and how to reduce them. Incidents and falls were recorded, investigated and used to identify learning.
“Staff had a very good understanding of these risks and how to ensure the safety and welfare of people.” from the report
Food suited to individual needs
People had choices and could ask for alternatives. Staff knew about allergies, dietary needs, likes and dislikes, and adjusted food and drinks when required.
“People were provided with nutritious meals in line with their needs and preferences.” from the report
Visible leadership
The manager was present and approachable. Staff said they felt supported, and inspectors found a stable management structure and shared focus on person-centred care.
“The registered manager was very visible in the service and provided strong and effective leadership” from the report
Controlled medicine disposal
needs fixingThe home had safe medicine systems overall, but inspectors recommended getting further advice about disposing of small amounts of controlled medicines.
“We recommended the registered provider seek further advice on the disposal of small amounts of controlled medicines.” from the report
Care plan records
needs fixingSome care plans did not reflect changes promptly, and older records had not always been archived. The manager and deputy were working to correct this.
“The registered manager had identified some information was not always updated in a timely way.” from the report
Staff supervision
needs fixingSupervisions had not been happening often enough. The manager had a plan to introduce regular supervision meetings, although staff said they felt supported.
“The registered manager told us that supervisions had not been taking place frequently and had a plan in place to address this.” from the report
- 01What advice did you obtain about the safe disposal of small amounts of controlled medicines, and what is your current process?
- 02How do you make sure care plans are updated promptly when a person's needs or routines change?
- 03How do you prevent old care records from being confused with current instructions?
- 04How often do staff now receive supervision, and how are agreed actions recorded?
- 05How are audit action plans recorded and checked to make sure improvements are completed?
This was an unannounced inspection covering all five CQC questions and the overall quality of the home. This explanation was written from the published report of 18 October 2016 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 Thalassa Nursing Home
2 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- June 2019Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- October 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 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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