CQC report explained · a residential care home
What the CQC found at The Manor House Thurloxton
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People said they felt safe, and the home had suitable visiting arrangements, PPE supplies and admission procedures. Before the inspection, PPE use, COVID-19 testing, cleaning records, policies and outbreak planning were not fully adequate.
- Effective?
- Good
- This question was not assessed during this targeted inspection.
- Caring?
- Good
- This question was not assessed during this targeted inspection.
- Responsive?
- Good
- This question was not assessed during this targeted inspection.
- Well-led?
- Good
- This question was not assessed during this targeted inspection.
What inspectors found, January 2021
The Manor House Thurloxton was inspected but not rated; a targeted visit found infection-control gaps during the pandemic, with most addressed afterwards, while the previous overall rating remained Good.
This was a targeted inspection about infection prevention and control during the COVID-19 pandemic. The inspector visited on 11 December 2020, spoke with four people, the provider and another staff member, and reviewed policies, risk assessments, cleaning records and visiting arrangements.
Before the inspection, staff were not using protective equipment correctly, regular COVID-19 testing was not in place, infection-control guidance was out of date and there was no written outbreak plan. Cleaning schedules did not cover all areas or high-touch surfaces.
During and after the inspection, staff used the required protective equipment. Weekly staff testing and testing for residents every 28 days were introduced. The provider also worked with local infection-control professionals on training, cleaning records, policies and an outbreak plan.
The service was not given a new rating because this inspection looked only at specific infection-control concerns. Its previous overall rating was Good, published in October 2017, and that rating remained unchanged.
People felt safe
People told inspectors they felt safe and were well cared for. There had been no reported COVID-19 cases at the time of the inspection.
“There had been no reported cases of COVID 19 within the service and people said they felt safe and were well cared for.” from the report
PPE supplies
The home had enough protective equipment for its current needs and possible outbreaks.
“The service had sufficient and adequate supply of PPE to meet current demand and foreseen outbreaks.” from the report
Visiting arrangements
Visits were arranged in advance and included protective equipment and temperature checks.
“Visitors booked appointment slots and were supported to wear personal protective equipment (PPE) and their temperature was checked before they met people living at the service” from the report
Action after inspection
The provider introduced regular testing and confirmed that staff had completed essential infection-control training after the inspection.
“Immediately following the inspection, the provider arranged for weekly testing of staff and testing for people using the service every 28 days, as per the guidance.” from the report
PPE was not used correctly before the visit
seriousBefore the inspection, staff were not using PPE effectively and the provider had not followed current guidance. This created a risk of infection transmission, although PPE was used correctly during the visit.
“Prior to the inspection, the provider was not using personal protective equipment (PPE) effectively to safeguard staff and people using the service.” from the report
Testing was not established
seriousThere was no regular COVID-19 testing programme before the inspection. The provider later introduced weekly staff testing and testing for people using the service every 28 days.
“No regular programme of testing had been implemented.” from the report
Cleaning records were incomplete
needs fixingThe premises looked clean, but the cleaning schedule did not cover every area or important high-touch surfaces. The provider was supported to develop better records and checks.
“The cleaning schedule did not include all areas of the premises, which staff are required to complete.” from the report
No written outbreak plan
needs fixingThere was no written plan for responding to a coronavirus outbreak. An infection-control nurse specialist was helping the provider develop one.
“The provider did not have a written contingency plan in place to address a possible coronavirus outbreak.” from the report
Guidance and training were out of date
needs fixingThe infection-control policy did not reflect current pandemic guidance, and staff had not received specific coronavirus infection-control or PPE training before the inspection.
“The provider's infection prevention and control policy did not reflect up to date and current infection control guidance, to take account of the pandemic.” from the report
- 01Can you show us the current records for weekly staff COVID-19 testing and testing of residents every 28 days?
- 02How do you check that staff use PPE correctly and have completed the required infection-control training?
- 03Does the cleaning schedule now include all areas and frequent cleaning of light switches, door handles, handrails and bedside tables?
- 04Can we see the written plan for responding to a coronavirus outbreak?
- 05What infection-control advice and support are you currently receiving from local health and social care professionals?
This was a targeted inspection of specific infection-prevention and control concerns; it did not assess the full key questions, so the previous ratings, including Good overall, carried over from the October 2017 inspection. This explanation was written from the published report of 8 January 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, October 2017
The Manor House Thurloxton was rated Good; inspectors found kind, personalised care, with some limits around night-time care and activities.
This was a comprehensive inspection over two visits on 23 and 29 August 2017. One visit was unannounced. The inspector spoke with all five people living there, two staff members, the provider and a family member involved in administration. They also reviewed care plans, staff files, accident records and other documents.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and well cared for. Staff knew people well, supported their choices and helped them remain independent. People also spoke positively about the food and about receiving help with health appointments.
The inspection found that medication records needed improving, but changes were made promptly during the inspection. The report also says the home could not provide regular night-time care in the long term if people's needs increased. There was no planned programme of activities, although people could follow their own interests and join in with activities when available.
The home was also rated Good at its previous inspection on 25 August 2015, so its overall rating remained unchanged.
Staff knew people well
The small team understood people's needs and had the skills and experience to support them.
“People were supported by a small team of staff who knew them well and had the skills and experience to meet their needs.” from the report
Personalised choices
People were supported to live in different ways according to their wishes, including choosing where to eat and how much independence to have.
“People were able to make choices about all aspects of their day to day lives.” from the report
Food and health support
People enjoyed freshly cooked food and were supported to receive medical attention and attend appointments.
“Family style cooking meant that there was one main choice at lunch time cooked freshly using good quality ingredients.” from the report
No planned activities programme
minorThere was no organised programme of activities. People could follow their own interests and take part in activities when they happened.
“There was no planned programme of activities in the home.” from the report
Mostly informal quality checks
minorQuality assurance was mainly based on close contact with people, relatives and staff. A formal six-monthly audit was planned but had not yet started at the inspection.
“The majority of the quality assurance in the home was informal and based on close contact with people living in the home, their relatives and staff.” from the report
- 01How would you support my relative if they began to need regular care during the night?
- 02What changes were made to medication records during the inspection, and how are records checked now?
- 03What activities or regular social contact would be available if my relative preferred to spend time in their room?
- 04Has the planned six-monthly formal quality audit started, and what has it found?
- 05How would you review and change my relative's care if their mobility or care needs increased?
This was a comprehensive inspection covering all five key questions, based on two visits, discussions with five people, two staff members and the provider, and reviews of care and service records. This explanation was written from the published report of 3 October 2017 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 The Manor House Thurloxton
2 rated inspections over 2 years: the service has held its Good rating throughout.
- January 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- October 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 30 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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