CQC report explained · a nursing home
What the CQC found at Thistle Lodge Robins Wood Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from abuse and avoidable harm. Risks were assessed, staff were trained, medicines were managed safely and lessons were learned from incidents, although the inspection followed earlier concerns about safeguarding delays and medicine errors.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward, but the report does not state that rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward, but the report does not state that rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward, but the report does not state that rating.
- Well-led?
- Good
- Inspectors found an open culture, visible management and better quality monitoring. People, relatives and staff were involved in giving feedback and the provider worked with other professionals to improve care.
What inspectors found, January 2024
Rated Good; inspectors found safer systems and stronger management, but the inspection followed earlier concerns about incidents, safeguarding and medicines.
Inspectors made an unannounced focused visit on 15 November 2023. They spoke with staff, relatives and care professionals, and reviewed care, medicines, recruitment, incident and management records. Only one person using the service chose to speak with them.
The home was rated Good overall. Safe and Well-led both improved from Requires Improvement at the previous inspection. Inspectors found that risks were assessed, medicines were managed safely, incidents were reviewed and staff were suitably trained.
The inspection was prompted by concerns about how incidents were managed and reported. The provider had taken action, including seeking specialist advice, improving audits and introducing more frequent incident monitoring. The other three ratings were not inspected and were carried forward from the previous inspection.
Learning from incidents
The home had introduced more frequent monitoring and reviewed incidents promptly. It used specialist advice and improvement plans to reduce the risk of problems happening again.
“All incidents were reviewed by the registered manager in a timely manner.” from the report
Safe medicines support
The provider completed a detailed medicines audit after errors, created an action plan and introduced a new process. Staff had medicines training and competency checks.
“A new process was implemented to ensure people received their medicines safely.” from the report
Individual risk planning
Inspectors found detailed assessments for restrictions and individual risks. Staff had clear guidance on how to support people when they became distressed.
“People's individual risks were fully assessed.” from the report
Open management
The management team was described as visible and approachable. Staff and relatives said they could raise concerns and were kept informed when things went wrong.
“There was a positive and open culture at the service.” from the report
Earlier safeguarding reporting delay
seriousThe inspection followed concerns that some safeguarding matters had not been reported to the local authority promptly. The provider reviewed its systems and inspectors found other concerns were reported in good time.
“Prior to our inspection we received concerns relating to a delay in the reporting of some safeguarding concerns to the local authority safeguarding team.” from the report
Recent medicine errors
seriousThere had been recent errors in giving medicines. The provider obtained specialist help and made changes, but families should check how these improvements are being monitored.
“Following recent medicine administration error's, the provider sought specialist support to undertake a full in-depth medicines audit and an action plan was created to ensure errors were learnt from and not repeated.” from the report
- 01What checks now make sure safeguarding concerns are reported to the local authority without delay?
- 02What changes were made after the recent medicine administration errors, and how do you check that they are still working?
- 03How are incidents reviewed for patterns, and can families see what improvements followed?
- 04What were the previous ratings for Effective, Caring and Responsive, which were carried forward rather than inspected this time?
- 05How are relatives and people using the service involved in reviewing care and giving feedback?
This was an unannounced focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection. This explanation was written from the published report of 5 January 2024 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 2023
Thistle Lodge Robins Wood Road was rated Requires Improvement; care was kind and personalised, but safety checks and management oversight were not always reliable.
This was the first inspection of this newly registered care home. Inspectors visited on 20 December 2022 and 18 January 2023. They spoke with people, relatives and staff, and reviewed care, medicines, recruitment and management records.
The home was rated Good for effective, caring and responsive care. Inspectors found kind staff, personalised support, suitable training, safe medicines administration and support for people's health, choices, communication and relationships.
It was rated Requires Improvement for safe and well-led care. Medicines stock checks were not always accurate, one incident involving restraint had not been identified through management review, and leaders did not always have clear roles or follow up issues promptly.
The overall rating Requires Improvement means the home was not consistently safe or well managed at the time of inspection. The provider took immediate action, including extra medicines stock checks, changes to management arrangements and improved oversight and auditing.
Kind and respectful staff
Inspectors saw people being spoken to warmly and respectfully. Staff supported people's dignity, choices and independence.
“We observed people were spoken to warmly and respectfully.” from the report
Personalised support
Care plans reflected people's needs, preferences, communication and equality needs. People were offered meaningful choices about meals and activities.
“Care was person-centred, supported people to have choice and met their needs and preferences.” from the report
Staff training
Staff had training suited to their roles and received support from the management and professional team.
“Staff were appropriately trained, inducted and provided with support by the management team and professionals within the multi-disciplinary team.” from the report
Health support
People were supported to access healthcare and maintain their health. Inspectors found medicines were stored and administered safely.
“Staff provided support to people which ensured they maintained good health.” from the report
Accessible communication
Information was provided in formats people could understand, and care plans explained how staff should interpret and support people's communication.
“The provider followed the Accessible Information Standard and ensured that people had information made available to them in a format that they understood.” from the report
Medicines stock checks
needs fixingMedicines were administered as prescribed, but stock checks were not always accurate because physical checks were not always completed.
“Medicines were administered as required but the stock checks were not always accurate because the provider had relied on the electronic system rather than completing a physical check.” from the report
Incident and restraint reviews
seriousManagement reviews did not always identify issues needing follow-up. One record showed inappropriate restraint methods had not been identified by the manager.
“We reviewed a record of an incident which indicated the inappropriate use of restraint methods which had not been identified by the manager.” from the report
Unclear management roles
needs fixingChanges in management had caused uncertainty about responsibilities. This created a risk that actions, including incident follow-up, might not be taken appropriately.
“Changes in management had led to a lack of clarity in the remit of different members of the management team.” from the report
Communication with professionals
needs fixingEngagement with outside professionals was not always timely. Feedback from families and professionals about communication was mixed.
“The provider did not always consistently work effectively in partnership with others.” from the report
Building independence
needs fixingOne person was not always given enough opportunity to develop skills and become more independent.
“The care and support offered to 1 person was not always provided in a way that empowered them.” from the report
- 01How are physical medicines stock checks now completed and recorded?
- 02How are incidents and any use of restraint reviewed, and how do you make sure lessons are followed up?
- 03What are the current management roles and who is responsible for checking safety and quality?
- 04How will my relative and our family be involved in care planning and kept informed?
- 05What specific opportunities will my relative have to build skills and become more independent?
This was the first inspection of the newly registered care home and covered all five CQC questions, including the premises, care and infection prevention and control. This explanation was written from the published report of 15 March 2023 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 Thistle Lodge Robins Wood Road
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- January 2024Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Thistle Lodge Robins Wood Road →
- March 2023Requires improvementSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Thistle Lodge Robins Wood Road →
- February 2022
Registered with the Care Quality Commission on 18 February 2022.
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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90 live-in carers within about an hour of Nottingham
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Most charge £980 to £1,270 a week. 73 can care for a couple. 11 years' experience on average.
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