CQC report explained · a nursing home
What the CQC found at Thirlestaine Park Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found systems to assess and manage falls and other risks. They also found safe medicines, safeguarding, fire safety and infection control arrangements, but some call bells were not answered within the home's preferred three minutes.
- Effective?
- Good
- This key question was not assessed during this targeted inspection.
- Caring?
- Good
- This key question was not assessed during this targeted inspection.
- Responsive?
- Good
- This key question was not assessed during this targeted inspection.
- Well-led?
- Good
- This key question was not assessed during this targeted inspection.
What inspectors found, September 2021
Inspected but not rated; the previous overall rating remains Good, with safe falls care and infection controls, but some call bells were answered slowly.
This was a targeted inspection on 11 and 12 August 2021. It followed notifications about serious injuries after falls. Inspectors looked mainly at falls prevention, falls management and infection control, rather than the whole service.
Inspectors found that risks were assessed and action was taken to reduce falls, pressure ulcers, poor nutrition, dehydration, choking and distress linked to dementia. Medicines were given as prescribed. Fire safety, building maintenance and infection control arrangements were also found to be in place.
Some people said they waited longer than they wanted for staff to answer their call bells. Records showed some responses took longer than the home's preferred three minutes, although none took more than nine minutes. Action was being taken to improve response times.
The service was inspected but not rated at this visit. Its previous overall rating of Good, published in January 2018, remained unchanged because this inspection did not cover the whole service.
Falls prevention
People's falls risks were assessed and reviewed. Staff followed procedures after falls and sought medical help when needed.
“People's risk of falls was assessed on admission and reviewed monthly, or sooner, if their circumstances altered.” from the report
Safe medicines
Inspectors found that medicines were given as prescribed. Staff also monitored medicines that could increase falls or other risks.
“People's medicines were managed safely, and people received their medicines as prescribed.” from the report
Infection control
Inspectors were assured that the home was following infection prevention measures, including testing, protective equipment and visiting arrangements.
“We were assured that the provider was using PPE effectively and safely.” from the report
Managing other risks
The home assessed risks such as pressure ulcers, poor nutrition, dehydration, choking and distress for people living with dementia.
“Potential choking risks were identified, and the texture of people's food altered accordingly.” from the report
Call bell delays
needs fixingSome people waited longer than the home's preferred three minutes for their call bells to be answered. Managers were taking action, and no recorded response took more than nine minutes.
“Some people told us they sometimes had to wait longer than they would prefer for staff to respond to their call bell.” from the report
No registered manager at the time
needs fixingThe home did not have a manager registered with CQC during the inspection. A new manager had been identified and was due to start in September 2021.
“At the time of the inspection this was not the case although a new home manager had been identified and was due to start in September 2021.” from the report
- 01How quickly are call bells currently answered, and how do you check this?
- 02What changes have been made since the inspection to improve call bell response times?
- 03Who is currently managing the home, and has the manager applied to register with CQC?
- 04How do you review falls and change each person's falls prevention plan after an incident?
- 05How do you make sure medicines linked to falls, bleeding or other risks are regularly reviewed?
This was a targeted inspection of falls prevention, falls management and infection control under Safe; the previous ratings and overall Good rating were not changed because the whole service was not assessed. This explanation was written from the published report of 3 September 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, January 2021
Targeted infection-control inspection; inspectors were assured that Thirlestaine Park Care Home was managing COVID-19 risks safely, but the service was not rated.
This was an announced, targeted inspection on 8 January 2021. It looked at infection prevention and control because the home had experienced a coronavirus outbreak.
Inspectors were assured that the home was using personal protective equipment correctly, testing people and staff, supporting isolation, and following social distancing and cleaning arrangements. They also found that infection-control policies and COVID-19 guidance were kept up to date.
Visits from relatives were suspended at the time, except for people at the end of their life. The home used technology to help people stay in touch and had prepared a safer visiting room for when visits restarted.
The service was inspected but not rated. This means the inspection checked infection-control arrangements only and did not give an overall quality rating.
Safe admissions
New residents were admitted after a negative COVID-19 test and were supported to isolate for up to 14 days.
“People were only admitted following a negative COVID-19 test result and supported to self-isolate for up to 14 days following admission” from the report
Regular testing
People and staff were tested in line with national guidance. Staff were tested before every shift.
“Staff were being tested prior to every shift.” from the report
Infection-control cleaning
Cleaning schedules had been increased and were being followed by housekeeping and care staff.
“Cleaning schedules had been enhanced and were followed by housekeeping staff and care staff.” from the report
Keeping families in touch
Although most visits were suspended, the home used technology to help residents remain in contact with relatives.
“Alternative ways, including the use of technology, had supported people's ability to remain in contact with their relatives.” from the report
Inspectors raised no specific concerns in this report.
- 01How are visits arranged now, and is the visiting room still being used?
- 02What happens if a resident tests positive for COVID-19 or needs to self-isolate?
- 03How often are residents and staff tested now?
- 04How do you make sure staff follow PPE, cleaning and social distancing procedures?
- 05How will relatives be supported to stay in contact if visiting has to stop again?
This was a targeted inspection of infection prevention and control practices only; the service was inspected but not rated and the other quality areas were not assessed. This explanation was written from the published report of 23 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.
Every inspection of Thirlestaine Park Care Home
3 rated inspections over 2 years: the service has held its Good rating throughout.
- September 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- January 2021Inspected but not ratedSafe: Inspected but not rated
- January 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2017Goodstayed GoodSafe: Requires improvement
- November 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2015
Registered with the Care Quality Commission on 1 February 2015.
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 £1,030 to £1,360 a week. 31 can care for a couple. 12 years' experience on average.
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