CQC report explained · a nursing home
What the CQC found at Thames View
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found suitable safeguarding, risk assessment, staffing, medicines and infection control arrangements. They noted that the fixed wiring certificate had expired and that fire drills had not involved residents.
- Effective?
- Good
- Care followed the Mental Capacity Act principles, staff had improved training and support, and people were helped to access healthcare and maintain good nutrition and hydration.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People and relatives were involved in care planning, and people's choices and routines were respected.
- Responsive?
- Good
- Care plans were individualised and included people's needs, preferences and interests. The home offered varied activities and had systems for responding to complaints.
- Well-led?
- Good
- Inspectors found better communication, regular audits and a more open culture where feedback was welcomed. There was no registered manager at the time, but a new manager was due to start soon.
What inspectors found, July 2021
Home of Compassion was rated Good; inspectors found kind, safe care and major improvements since the previous inspection.
Inspectors visited on 10 June 2021. They spoke with people living at the home, relatives, staff and a healthcare professional. They also checked care records, medicines, recruitment files, health and safety records and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines management, good infection control, suitable training and kind support. People's care plans reflected their needs and preferences, and there was a varied activities programme.
The previous inspection had rated the home Requires Improvement and found several breaches of regulation. At this inspection, the report says improvements had been made and the home was no longer in breach of regulations.
Kind and respectful care
People described a friendly atmosphere and positive relationships with staff. Inspectors observed staff supporting people calmly and respectfully.
“We observed that staff demonstrated these behaviours during our inspection, engaging with people in a way that was kind, caring and respectful.” from the report
Enough staff
People said they did not have to wait for help or feel rushed. Staffing levels were based on people's assessed needs and reviewed monthly.
“People told us that staff were available when they needed them.” from the report
Personalised activities
The home offered activities based on people's interests and needs, including activities adapted for visual impairment and dementia.
“There was a full and varied programme of activities which was based on people's individual needs and interests.” from the report
Improved leadership and monitoring
Communication and feedback had improved since the previous inspection. Managers carried out regular checks on care plans, medicines, infection control and safety.
“There were effective systems of quality monitoring, which ensured that people received well-planned and managed care.” from the report
Electrical safety certificate
needs fixingThe home's fixed wiring certificate had expired at the end of April 2021. A contractor visit had been delayed because of COVID-19 restrictions and was rescheduled for the week after the inspection.
“The home's fixed wiring certificate had expired at the end of April 2021.” from the report
Fire drills did not involve residents
needs fixingFire drills took place every three months, but residents had not taken part. The deputy manager said future drills would include partial or lateral evacuation and evacuation equipment.
“Fire drills had not involved the participation of people who lived at the home” from the report
No registered manager at the visit
minorThe home did not have a manager registered with the CQC when inspectors visited. A new manager had been appointed and was due to start two weeks later.
“The service did not have a manager registered with the Care Quality Commission.” from the report
- 01Has the fixed wiring certificate now been renewed, and were any problems found?
- 02How do fire drills now involve residents, including people who may need help to evacuate?
- 03Did the new manager start as planned, and are they now registered with the CQC?
- 04How will you make sure end of life care plans reflect each person's wishes and needs?
- 05How are residents and relatives' feedback and complaints used to make further improvements?
This was a planned inspection based on the previous Requires Improvement rating and covered all five key questions, including infection prevention and control under Safe. This explanation was written from the published report of 22 July 2021 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, March 2021
Inspected but not rated; inspectors found strong infection control, testing, cleaning and vaccination arrangements.
This was an announced, targeted inspection on 4 March 2021. It looked only at infection prevention and control during the COVID-19 pandemic.
Inspectors were assured that the home had suitable arrangements for PPE, testing, visiting, social distancing, admissions and managing outbreaks. The home used zoning to help separate areas and reduce the spread of infection.
The home was clean and tidy. Cleaning included high-touch areas, was carried out three times a day and was checked through daily records and audits. People had access to varied food, which helped those recovering from COVID-19 improve their weight.
The service was inspected but not rated. This report does not provide a full rating for the home or assess all five areas of care.
Clean environment
The home was clean and tidy, with high-touch areas included in cleaning three times a day. The cleaning rota was checked daily and audited.
“The home was kept clean and tidy in all areas.” from the report
Testing and PPE
There was a strong supply of PPE and a testing process for people and staff. The home could also provide PPE to other homes in the area.
“The provider had implemented a robust testing procedure for staff and residents.” from the report
Vaccination support
People and staff were supported to access COVID-19 vaccination. Everyone who could receive it had received their first dose, with second doses booked.
“People and staff had been supported with access to the COVID-19 vaccine.” from the report
Infection control layout
Zoning helped separate areas of the home during the pandemic and was intended to reduce the spread of infection.
“This enabled staff to be able to minimise the spread of infection by ensuring areas of the home could be separated to keep people safe.” from the report
Inspectors raised no specific concerns in this report.
- 01How are the cleaning rota and daily audits carried out now, including cleaning of high-touch areas?
- 02What testing arrangements are currently in place for residents, staff and visitors?
- 03How does the home manage infection outbreaks and separate areas when needed?
- 04What are the current visiting arrangements, and what checks and protective equipment are required?
- 05Can you provide information about the home's performance in caring, effectiveness, responsiveness and leadership, which this inspection did not assess?
This was a targeted inspection of infection prevention and control only; the service was inspected but not rated and the other areas of care were not assessed. This explanation was written from the published report of 25 March 2021 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 Thames View
3 rated inspections over 4 years: the service has held its Good rating throughout.
- July 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2021Inspected but not ratedSafe: Inspected but not rated
- September 2020Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- April 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016
Registered with the Care Quality Commission on 10 May 2016.
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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