CQC report explained · a residential care home
What the CQC found at Thornbury Villa
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm, and there were enough staff to meet people's needs. Inspectors found that some risk information was difficult to locate during the move to electronic records, and some as-required medicine protocols were missing.
- Effective?
- Good
- People's needs were assessed, staff had suitable training and people received support with food, drink and health care. Some parts of the building needed work, including en-suite facilities, storage and decoration.
- Caring?
- Good
- Staff were kind, attentive and respectful. People were involved in decisions, and their privacy, dignity, preferences and independence were supported.
- Responsive?
- Good
- Care reflected people's individual needs and preferences. People had activities and support to maintain family contact, although some care records needed updating during the electronic system change.
- Well-led?
- Good
- The provider and manager were open about improvements needed, sought feedback and had a clear management structure. However, the home had been without a registered manager since May 2021, and its new quality systems were not yet fully embedded.
What inspectors found, October 2022
Thornbury Villa is rated Good; inspectors found kind, safe care, but records and management systems were still being improved.
Inspectors visited unannounced on 24 and 30 August 2022. They spoke with people living there, relatives, staff, the provider and the manager. They observed care and checked care, medicine, recruitment, training and quality records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and were happy with their care. Inspectors found enough staff, safe recruitment, suitable support with medicines, good infection control and access to health professionals.
Care was described as kind and respectful. People were supported to make choices, stay independent, keep in touch with family and take part in activities. The home was also providing compassionate end of life care.
Some systems were still being moved from paper to electronic records. This made information harder to find and sometimes led to duplicated or outdated records. Some as-required medicine instructions were missing, and the home did not have a registered manager in post.
Enough suitable staff
Inspectors found enough staff to meet people's needs. Recruitment checks included references and Disclosure and Barring Service checks.
“There were sufficient numbers of staff to meet the needs of people at the service.” from the report
Kind and respectful care
People and relatives gave positive feedback about staff. Inspectors saw staff treating people with kindness, protecting their dignity and supporting their choices.
“Staff were kind, friendly and attentive to people and we saw positive interactions between staff and people.” from the report
Food and mealtimes
People were supported with nutrition and hydration. They could choose where to eat and were offered alternatives when needed.
“We saw the mealtime experience was relaxed and sociable and people could choose where they ate their meals.” from the report
Activities and family contact
People had activities such as film nights and pampering sessions. Staff also supported people to maintain contact with family and friends.
“Staff supported people to maintain contact with their families and friends, along with providing activities for people to participate in.” from the report
Good partnership working
Staff worked with GPs, district nurses and other health professionals when people's needs changed.
“People had access to healthcare services and other professionals according to their needs.” from the report
Care records were hard to find
needs fixingInformation was split between paper and electronic systems during the changeover. Some records needed updating or contained duplicated information, which could confuse staff about the support required.
“Current and past information was kept electronically, or paper based.” from the report
Some medicine instructions missing
needs fixingSome records did not contain protocols for medicines prescribed as required. These instructions help staff know when such medicines should be offered.
“However, we found protocols missing in some records for medicines prescribed 'as required' or PRN.” from the report
No registered manager in post
needs fixingThe home had been without a registered manager since May 2021. A new manager had been appointed and planned to submit an application to CQC.
“The service has been without a registered manager since May 2021.” from the report
Some building work needed
minorInspectors noted that some en-suite facilities, storage areas and decoration needed improvement. The provider was working with architects on upgrades and refurbishment.
“Some parts of the building required work in relation to en-suite facilities, storage and decoration.” from the report
- 01Has the move from paper to electronic records been completed, and how do you make sure staff can quickly find current risk and care information?
- 02Have protocols now been added for every medicine prescribed as required?
- 03Has the new manager applied to become the registered manager, and what is the current position?
- 04What work has been completed on en-suite facilities, storage and decoration, and what remains to be done?
- 05How will you make sure care plans stay up to date and do not contain duplicated information?
This was an unannounced inspection of the newly registered care home covering all five key questions, including infection prevention and control; the previous Outstanding rating was under the previous provider. This explanation was written from the published report of 7 October 2022 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, May 2021
Inspected but not rated; inspectors found strong Covid-19 infection control and safe visiting arrangements.
This was an unannounced, targeted inspection on 21 April 2021. It checked the home's infection prevention and control measures during the Covid-19 pandemic.
Inspectors were assured that the home used PPE safely, carried out testing, supported social distancing and shielding, and had suitable cleaning and hygiene arrangements. They were also assured that the home could prevent or manage infection outbreaks.
The home changed ownership on 1 February 2020, and this was its first inspection. The service was inspected but not rated, so this report does not give an overall quality rating.
Covid-19 awareness
Staff understood the importance of keeping people safe from Covid-19. The provider's policies and training supported this.
“People were being looked after by staff who understood the important of keeping people safe from Covid 19.” from the report
PPE and testing
The home had enough PPE, used it appropriately and tested people and staff in line with government guidance.
“There was a good stock of PPE which was worn and disposed of appropriately.” from the report
Visiting arrangements
Visits were planned around people's choices and individual risks. Visiting could take place in bedrooms, the conservatory or garden.
“Individual visiting risk assessment were completed with each person and, visiting arranged in people's own rooms, the conservatory and/or garden.” from the report
Activities and cleaning
An activity coordinator was employed, and extra cleaning took place, including after visits.
“The provider has employed an activity coordinator to ensure there was a member of staff available to be with people to keep them occupied.” from the report
Inspectors raised no specific concerns in this report.
- 01How are PPE, testing and infection control arrangements managed now?
- 02How are visits arranged, and are individual visiting risk assessments still completed?
- 03How is the activity coordinator role being used to keep residents occupied?
- 04What checks are made after visits to ensure extra cleaning is completed?
- 05When were the home's other care areas, such as medicines, staffing and caring, last fully assessed?
This was a targeted inspection of infection prevention and control during the Covid-19 pandemic; the service was inspected but not rated and the other key questions were not covered. This explanation was written from the published report of 12 May 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 Thornbury Villa
4 rated inspections over 7 years: the service has held its Good rating throughout.
- October 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2021Inspected but not ratedSafe: Inspected but not rated
- January 2020Outstandingup from GoodSafe: GoodEffective: OutstandingCaring: OutstandingResponsive: GoodWell-led: Good
- May 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2021
Registered with the Care Quality Commission on 1 February 2021.
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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