CQC report explained · a residential care home
What the CQC found at Visitation of Our Lady Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about infection prevention and control, including PPE, testing, ventilation, cleaning, safe admissions and outbreak management. Staffing pressures related to COVID-19 were also discussed.
- Effective?
- Good
- This area was not assessed in this targeted inspection.
- Caring?
- Good
- This area was not assessed in this targeted inspection.
- Responsive?
- Good
- This area was not assessed in this targeted inspection.
- Well-led?
- Good
- This area was not assessed in this targeted inspection.
What inspectors found, February 2022
Visitation of Our Lady Residential Care Home was inspected but not rated; inspectors found good COVID-19 infection control and visiting arrangements.
This was an announced, targeted inspection on 18 January 2022. The inspection focused on infection prevention and control, visiting arrangements and whether COVID-19 staffing pressures affected care.
Inspectors found the home was clean and had a cleaning rota, PPE stations, suitable waste bins and regular ventilation. There were processes for testing, managing outbreaks and supporting safe visits.
The home met the requirement for non-exempt staff and visiting professionals to be vaccinated against COVID-19. CQC was assured about the main infection control arrangements it checked.
The home was inspected but not rated. This means the visit did not give an overall quality rating or ratings for all five areas of care.
Infection control
The home had cleaning arrangements, PPE stations, clinical waste bins and regular ventilation in communal areas.
“We saw the home was clean and a cleaning rota was in place for the Sisters.” from the report
Testing and outbreak planning
There was a clear process for COVID-19 testing and a plan for managing outbreaks, including enhanced PPE and bedroom-based care where needed.
“The registered manager had a clear process for COVID-19 testing of both people living at the home and the Sisters.” from the report
Safe visiting
People were supported to see family and friends, with appointments, temperature checks and suitable protective equipment for visitors.
“People living at the home were supported to have visitors and appropriate checks were carried out to comply with current guidance.” from the report
Staff vaccination
The report says the home met the COVID-19 vaccination requirement for non-exempt staff and visiting professionals.
“The service was meeting the requirement to ensure non-exempt staff and visiting professionals were vaccinated against COVID-19.” from the report
Inspectors raised no specific concerns in this report.
- 01How are visitors currently booked in, checked and supported to meet residents?
- 02How often are residents and staff tested, and what happens if someone tests positive?
- 03What is the current plan for managing an infection outbreak in the home?
- 04How would staffing pressures affect the care provided if staff were unavailable?
- 05When was the home last assessed on the other areas of care that this inspection did not cover?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19 staffing pressures; it did not assess the other four key questions or give an overall rating. This explanation was written from the published report of 23 February 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, November 2017
Rated Good; inspectors found safe, kind and responsive care, with some records and training still needing attention.
This was an unannounced, comprehensive inspection on 24 October 2017. Inspectors spoke with people living there, relatives, staff and healthcare professionals. They observed care and checked care plans, staff records, medicines records and management records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people received their medicines safely, had enough staff support, and had their health, food and personal care needs met.
People and relatives described kind and respectful care. Staff knew people well and supported their emotional, spiritual and cultural needs. Care plans were reviewed regularly, activities reflected people's interests, and people knew how to complain.
The home had been in breach of two regulations at the October 2016 inspection. This inspection found that action had been taken and improvements had been made. Inspectors still identified some matters to address, including emergency evacuation plans, end-of-life care records and some staff training records.
Kind and respectful care
Inspectors saw staff treating people gently and respectfully. Staff knew people's likes, dislikes and routines and supported their dignity.
“All staff displayed a gentle and patient approach throughout the day when caring for people in the home.” from the report
Safe medicines and staffing
Medicines records were clear and complete, and staff had received medicines training. Staff lived at the home and were available to provide support at all times.
“These records were clear and fully completed and showed people were receiving their medicines when they needed them.” from the report
Personalised support
Care plans included individual preferences and routines. Staff adapted activities and their way of communicating to each person.
“Each person's care plan was based on their needs, abilities, likes, dislikes and preferences.” from the report
Improvements since 2016
The home had acted on the previous inspection's concerns about medicines and quality checks. Inspectors found that audits were now being carried out and improvements had been made.
“At this comprehensive inspection we found the provider had taken action to address the breaches we had identified and improvements had been made.” from the report
Emergency evacuation plans
needs fixingPeople's records did not contain personal emergency evacuation plans during the inspection. The manager said this would be addressed, and the report says work had started after the visit.
“People's care records did not contain Personal Emergency Evacuation Plans (PEEPs).” from the report
Some training was not recent
needs fixingStaff had received regular training overall, but dementia and Mental Capacity Act training was not recent. The manager said further training would be organised.
“Staff told us they had received training in dementia and MCA, although not recently.” from the report
Medicines competency records
needs fixingStaff who gave medicines had completed training, but the report found no written competency assessments showing that their practical ability had been formally recorded.
“There were no written competency assessments, however the registered manager told us they ensured that all staff followed the correct procedures when administering medicines.” from the report
End-of-life care records
minorPeople's last wishes were recorded, but separate end-of-life care plans were not available. The manager said this would be recorded in future.
“People's last wishes were recorded in their care plans although there were no 'end of life' care plans available.” from the report
- 01Have personal emergency evacuation plans now been completed for every resident, and when are they reviewed?
- 02How do you check that staff are competent to administer medicines, as well as trained to do so?
- 03When was each staff member's most recent dementia and Mental Capacity Act training?
- 04How are a resident's end-of-life wishes recorded and shared with staff and relatives?
- 05What changes were made after the previous inspection's concerns about medicines management and quality audits?
This was an unannounced comprehensive inspection covering all five questions and checking whether improvements had been made since the previous inspection on 4 October 2016. This explanation was written from the published report of 22 November 2017 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 Visitation of Our Lady Residential Care Home
3 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at Visitation of Our Lady Residential Care Home →
- November 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Visitation of Our Lady Residential Care Home →
- November 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 7 January 2011.
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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