CQC report explained · a nursing home
What the CQC found at Trowbridge Oaks Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from avoidable harm, with risks assessed and enough staff seen on the day. Medicines systems had improved, but one expired medicine and some incomplete 'when required' instructions were found.
- Effective?
- Good
- This rating improved from Requires Improvement. Records showed better decision-making for people who lacked capacity, and people received support with food, healthcare, training and assessments.
- Caring?
- Good
- This key question was not inspected during this focused visit.
- Responsive?
- Good
- This key question was not inspected during this focused visit.
- Well-led?
- Good
- Inspectors found visible and approachable management, quality checks and systems for learning and improvement. People, relatives and staff said the home was well managed.
What inspectors found, October 2021
Trowbridge Oaks Care Home was rated Good; inspectors found kind, safe care, but medicines systems still needed attention.
Inspectors made an unannounced focused visit on 30 September 2021. They looked at Safe, Effective and Well-led, after concerns about medicines and how people were cared for. They spoke with people, relatives and staff, and checked care, medicines, recruitment and management records.
The home was clean and well maintained. People were treated with respect, had their medicines as prescribed at the time of inspection, and received support with food, healthcare and risks. Infection control arrangements were in place, including testing, visitor screening and suitable use of protective equipment.
Some medicines problems had been identified before the inspection. The home had improved ordering systems, but one medicine had passed its in-use expiry period and some instructions for 'when required' medicines did not contain enough personal detail. The home also faced staff shortages, although inspectors found enough staff on the day.
The overall rating was Good. Effective improved from Requires Improvement at the previous inspection, while Safe and Well-led remained Good. Caring and Responsive were not inspected during this focused visit, so their previous ratings were used in the overall rating.
Respectful care
Inspectors saw people being treated with respect and kindness. People and relatives said they felt safe and well looked after.
“People were supported to have maximum choice and control of their lives” from the report
Infection control
The home used visitor screening, testing, social distancing and protective equipment. Inspectors found there was plenty of protective equipment available.
“We were assured that the provider was using PPE effectively and safely.” from the report
Food and mealtimes
People could choose their meals and alternatives. Staff provided support in a calm and unhurried way.
“People were able to choose their meals daily.” from the report
Management and improvement
Management was described as visible and approachable. Audits and other checks were used to monitor quality and identify improvements.
“Quality monitoring systems were in place to audit and regularly check all of the service.” from the report
Medicine supply problems
seriousBefore the inspection, some people had missed medicines because supplies were not available. The home had taken action and inspectors did not see anyone miss a dose because of stock problems during this visit.
“There had been incidents where people had not received their medicines as prescribed due to lack of stock.” from the report
Medicine expiry check
needs fixingOne medicine had not been removed after its in-use expiry period. The home removed it during the inspection.
“However, we did see one medicine which had not been disposed of after it's in-use expiry period.” from the report
Instructions for as-needed medicines
needs fixingSome instructions did not explain clearly enough when a person's 'when required' medicine should be given. Inspectors said this could mean staff did not always give it as intended.
“However, some lacked person-centred detail on when the medicine should be administered.” from the report
Staff shortages
needs fixingThe home had experienced staffing difficulties and could not always find agency staff when there was short-notice sickness. Inspectors nevertheless saw enough staff to respond to people promptly on the day.
“This was not always possible, as there was also a shortage of agency staff.” from the report
- 01How do you now make sure medicines are ordered in time and nobody misses a dose because of a lack of stock?
- 02How do you check that medicines are removed when they pass their in-use expiry date?
- 03How do staff decide when to give each person's 'when required' medicine, and are the instructions personalised?
- 04What are the current staffing levels, and how often are agency staff needed because of sickness or vacancies?
- 05How are decision-making and best-interest records kept up to date for people who lack capacity?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 29 October 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, September 2019
Rated Good; inspectors found kind, safe care, but consent and care records needed improvement.
This was an unannounced inspection on 28 and 30 August 2019. The inspector spoke with people, relatives and staff, observed care, and checked care plans, medicines records, recruitment records and management audits.
The home was rated Good overall. Safe, Caring, Responsive and Well-led were rated Good. Staff were described as friendly and kind, people said they felt safe, staffing was sufficient, and medicines were generally managed safely.
Effective was rated Requires Improvement. Inspectors found inconsistent mental capacity and consent records, some care plans that had not been updated, and gaps in records about people's daily care and wellbeing. The home had started work to address some of these issues.
The overall rating stayed Good compared with the previous inspection. However, Effective fell from Good to Requires Improvement.
Kind and respectful staff
People and relatives consistently praised the staff. Inspectors observed staff being attentive, friendly and respectful of people's dignity.
“We observed kind and caring interactions between staff and people.” from the report
People felt safe
Risks such as falls, moving and handling, and choking had been assessed. People and relatives said staff helped them feel safe.
“People and their relatives told us staff helped them to feel safe.” from the report
Enough trained staff
The home was fully staffed according to its dependency calculations. Staff received induction, ongoing training, supervision and opportunities to ask for more training.
“The home was fully staffed in accordance with the dependency calculations.” from the report
Activities and community links
People could join activities, outings, celebrations and religious services. Relatives and community groups were also involved in events.
“There were some creative and person-centred activities and events at the home.” from the report
Generally safe medicines practice
Medicines were stored securely and nurses followed safe administration practices. There were also regular medicines audits.
“We saw the nursing staff following best practice guidance to ensure safe medicines administration.” from the report
Mental capacity and consent records
seriousSome assessments and consent records were incomplete or inconsistent. Inspectors said one person could potentially have been deprived of their liberty without the appropriate assessment.
“This meant the person could potentially be deprived of their liberty without appropriate assessment to do so.” from the report
Care plans and daily records
needs fixingSome care plans were not updated when people's needs changed. Daily records did not consistently show people's choices or observations of their wellbeing.
“Records of people's day to day care and support were task focussed.” from the report
Diabetes and behaviour records
needs fixingSome people without insulin did not have specific diabetes care plans. One person's diabetes monitoring changes had not been added to the relevant care plan, and behaviour records had gaps.
“We found for one person there had been changes in how their diabetes was to be monitored, but this had not been updated in their care plan.” from the report
Cream and lotion records
minorMedicine administration records were up to date overall, but there were gaps showing whether prescribed creams and lotions had been applied.
“Medicine administration records were up to date, however there were gaps in the records for the application of prescribed creams and lotions.” from the report
- 01How do you now complete and check mental capacity assessments, best-interest decisions and DoLS applications?
- 02How do you make sure consent is recorded before sharing photographs or storing care plans in bedrooms?
- 03How are care plans updated promptly when a person's needs, diabetes monitoring or behaviour changes?
- 04How do daily records show a person's choices, wellbeing and any changes noticed by staff?
- 05What has changed to give people visual meal choices and pictorial menus?
This was an unannounced, planned inspection covering all five CQC questions, and the home was providing personal and nursing care to 45 people. This explanation was written from the published report of 7 September 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.
Every inspection of Trowbridge Oaks Care Home
3 rated inspections over 5 years: the service has held its Good rating throughout.
- October 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2019Goodstayed GoodSafe: GoodEffective: Requires improvementWell-led: Good
- February 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 November 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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