CQC report explained · a nursing home
What the CQC found at Time Court Residential and Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found effective systems to protect people from abuse and manage risks. Medicines were stored, administered and recorded safely, and people said they received them on time.
- Effective?
- Requires improvement
- The home assessed people's care needs and supported access to health professionals. However, the environment was not fully adapted for people living with dementia, and the menu did not fully cater for different cultures and cuisines.
- Caring?
- Good
- People and relatives described staff as kind and caring. Inspectors saw staff treating people with dignity, supporting independence and involving people in decisions about their care.
- Responsive?
- Good
- Care plans were personalised and regularly reviewed. Activities were available and complaints had been investigated, but people said opportunities for outdoor activities were limited.
- Well-led?
- Good
- Inspectors found clear management structures, an open culture and regular checks on areas such as medicines, infection control and accidents. The service was working to improve, although more creative dementia support was needed.
What inspectors found, August 2019
Time Court Residential and Nursing Home was rated Good overall, but inspectors found that dementia support and the environment needed improvement.
This was an unannounced comprehensive inspection on 22 May 2019. Inspectors spoke with people living in the home, relatives and staff. They reviewed care records, medicines records, staff files and management information.
The home was rated Good overall. Safe, caring, responsive and well-led were rated Good. Inspectors found that people were protected from abuse, received kind and respectful care, had personalised support and benefited from regular monitoring of the service.
Effective was rated Requires Improvement. The environment was not fully adapted for people living with dementia. The menu also did not fully meet different cultural needs, and people said outdoor activities were limited. The home had started work to address some of these issues.
Safe care
Inspectors found that people were protected from abuse and avoidable harm. Staff understood how to recognise and report concerns.
“People who used the service were protected from the risk of harm and abuse.” from the report
Safe medicines
Medicines were stored securely and records were accurate. Staff had training and competency checks, and people said medicines were given at the right time.
“Medicines were managed consistently and safely in line with national guidance.” from the report
Kind and respectful staff
People and relatives said staff were caring and respectful. Inspectors observed patient support during moving and handling and at mealtimes.
“Staff treat you kindly. They can't do any better than that.” from the report
Personalised support
Care plans covered people's communication, mobility, continence, skin and nutrition needs. Staff reviewed plans and acted on changes.
“People's support plans were regularly reviewed by staff.” from the report
Open management
The home had clear management arrangements and systems for gathering feedback and checking the quality of care.
“There was an open culture within the service.” from the report
Dementia-friendly environment
needs fixingThe building did not include enough signs, familiar objects or contrasting features to help people living with dementia orient themselves. CQC recommended that the home seek specialist advice.
“The environment was not fully adapted to meet the specific needs of people with dementia.” from the report
Cultural food choices
minorThe menu did not fully provide for different cultures and cuisines. The home was working to improve this.
“However, we found the food menu not to fully cater for different cultures and cuisines.” from the report
Limited outdoor activities
minorPeople and relatives said there were few opportunities to go outside. The home was considering buying a bus and was asked to find more creative ways to improve outdoor activities.
“However, people told us outdoor activities were limited.” from the report
- 01What changes have been made to make the environment more suitable for people living with dementia?
- 02Are there now signs, familiar objects, contrasting features and dementia-friendly equipment in the home?
- 03How does the current menu meet residents' different cultural and religious food preferences?
- 04How often can residents go outside, and what outdoor activities are available for people who need help to leave the home?
- 05What actions were taken after the inspection to improve the areas rated Requires Improvement?
This was an unannounced comprehensive inspection covering the premises and care, with ratings given for all five CQC questions. This explanation was written from the published report of 2 August 2019 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, November 2016
Rated Good overall, with Outstanding leadership; inspectors found kind, safe care but noted a few record-keeping errors.
This was an unannounced, comprehensive inspection on 20 October 2016. Inspectors spoke with people, relatives, staff and visiting healthcare professionals. They observed care and checked care plans, medicines records, staff records, audits and safety records.
The home provided accommodation and personal care for up to 56 people. There were 41 people living there during the inspection. Inspectors found people were protected from abuse, risks were generally managed safely, staffing was sufficient and medicines were managed safely.
People received care suited to their needs. Staff were trained and supported, treated people kindly, respected privacy and involved people in decisions. The home offered activities and responded to complaints and feedback.
The overall rating was Good. Safe, Effective, Caring and Responsive were all rated Good. Well-led was rated Outstanding because people were involved in running the home, staff shared clear values and leaders used feedback and audits to improve the service.
Enough staff
Inspectors saw enough staff to respond promptly to people, including to call bells. Staffing was adjusted when people's needs increased.
“There were sufficient staff on duty to meet people's needs.” from the report
Skilled staff
Staff received induction, regular training, supervision and annual appraisals. Additional training was arranged to help staff support people's needs.
“Staff were supported in their roles through training, supervision and an annual appraisal of their performance.” from the report
Kind and respectful care
Staff were patient, friendly and considerate. People said their privacy was respected and inspectors observed positive relationships between staff and people.
“People were treated with kindness and consideration by staff.” from the report
Individual care and activities
Care plans included people's needs, life histories and preferences. The home offered activities, one-to-one time and support for important personal events.
“People received care and support which met their individual needs and preferences.” from the report
Strong leadership
People were involved in decisions about the home, including staff interviews and service improvements. Audits and feedback were used to identify and address problems.
“The provider had quality assurance systems in place to identify issues and drive improvements.” from the report
Incorrect malnutrition score
minorOne person's malnutrition risk assessment was scored incorrectly. Inspectors said the person's support was still appropriate and the risk was being safely managed, but the record needed correcting.
“one person's malnutrition risk assessment had not been scored accurately.” from the report
Medicine label error
minorOne boxed medicine had a label referring to a higher dose than the tablets inside. Staff contacted the GP during the inspection and confirmed the person had received the correct dose.
“the dispensing label on one person's boxed medicine was inaccurate, referring to a higher dose tablet than the box contained.” from the report
Some recruitment records incomplete
minorStaff files did not always show that gaps in employment had been considered. The provider later confirmed that full work histories had been obtained for the files reviewed and that its paperwork had been updated.
“we noted that gaps in employment had not always been considered.” from the report
Care plan did not show an outing condition
minorOne person's care plan did not mention an outings condition attached to their DoLS authorisation. The manager arranged for the care plan to be updated during the inspection.
“one person's care plan made no reference to them being supported to undertake outings from the service, which was a condition placed on their current DoLS authorisation.” from the report
- 01How do you make sure malnutrition risk assessments are scored correctly and reviewed after an error?
- 02What checks are now made to ensure medicine labels match the medicines and prescribed doses?
- 03How do you make sure every DoLS condition is included in the person's care plan and followed?
- 04How do you decide staffing levels on each unit when people's needs change?
- 05How are activities and meal times adapted when residents give different views or preferences?
This was an unannounced comprehensive inspection covering all five key questions and the overall quality of the home. This explanation was written from the published report of 26 November 2016 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 Time Court Residential and Nursing Home
2 rated inspections over 3 years: the service has held its Good rating throughout.
- August 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Time Court Residential and Nursing Home →
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Outstanding
Read what inspectors found at Time Court Residential and Nursing Home →
- January 2014
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 16 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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