CQC report explained · a nursing home
What the CQC found at Cathedral Care Centre
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found that some environmental risks were not managed properly. Sharps, needles and thickening powder were accessible, although the home took immediate action to remove the items and replace window restrictors.
- Effective?
- Requires improvement
- This question was not separately rated in this inspection report. Inspectors said the home worked within the Mental Capacity Act and had appropriate authorisations where needed.
- Caring?
- Good
- This question was not separately rated in this inspection report. Inspectors observed good interactions, and people and relatives gave positive feedback about the care.
- Responsive?
- Good
- This question was not separately rated in this inspection report. Inspectors said complaints were monitored and acted on, but communication with relatives needed to improve.
- Well-led?
- Requires improvement
- Management changes reduced stability and contributed to delays in reporting a safeguarding incident. Quality systems did not identify some environmental risks, although several audits were effective.
What inspectors found, September 2023
Cathedral Care Centre was Rated Requires Improvement; inspectors found kind care and safe medicines, but environmental risks and leadership systems needed improvement.
This was an unannounced inspection on 27 June 2023. Inspectors spoke with people living at the home, staff, managers and 18 relatives. They also checked care records, medicines, staffing, training and quality checks.
People and relatives generally said they felt safe. Staff understood safeguarding, there were enough staff, medicines were administered safely and infection control arrangements were suitable. Inspectors also saw kind interactions between staff and people.
The home was not always safe or well-led. Sharps, needles and thickening powder were accessible to people, and there was a delay in reporting a safeguarding incident. Frequent management changes affected communication and oversight. The overall rating remains Requires Improvement, as it was at the previous inspection published in January 2021.
People felt safe
People and relatives told inspectors they felt safe. Staff had safeguarding training and understood how to reduce the risk of harm.
“People and relatives told us they felt the service was safe.” from the report
Safe recruitment
The home had a recruitment process that included references and criminal record checks. Inspectors also found enough staff to meet people's needs.
“A safe recruitment process was in place, where references were obtained and also Disclosure and Barring Service (DBS) checks.” from the report
Medicines
Staff were trained to administer medicines. People received their prescribed medicines safely and in their preferred way.
“People received their prescribed medicines safely and in their preferred way.” from the report
Positive interactions
Inspectors saw good relationships between staff and people. Staff knew the people they supported well.
“We observed good interactions between staff and people, and they knew the people they were supporting well.” from the report
Unsafe access to equipment and products
seriousSharps, diabetic equipment and thickening powder were accessible to people. Inspectors said this increased the risk of harm, although the items were removed after the concerns were raised.
“We found sharps and diabetic equipment not stored appropriately and accessible to people.” from the report
Delayed safeguarding notification
seriousA safeguarding incident was reported to the local authority three months late. Inspectors said no harm occurred, but the delay showed that reporting systems were not reliable enough.
“However, there had been a 3 month delay in submitting an incident notification to the local authority adults safeguarding team.” from the report
Checks and competency records
needs fixingOne staff member had not had a DBS status check since 2016. Agency staff had medicines training, but the provider had not completed the competency checks required by its own policy.
“However, we found this had not been fully implemented and one staff member had not been checked since 2016.” from the report
Management stability and communication
needs fixingFrequent management changes affected communication with relatives and made it harder to sustain improvements. There was no registered manager in post when inspectors visited.
“The provider failed to sustain consistent management at the service. Multiple changes to the management reduced their ability to sustain improvement.” from the report
- 01How are sharps, needles, diabetic equipment and thickening powder now stored so that people cannot access them?
- 02Who is currently responsible for managing the home, and what is the plan for providing a stable registered manager?
- 03How do you make sure safeguarding incidents are reported without delay?
- 04Have all staff now had the required DBS checks and medicines competency assessments?
- 05How will you keep relatives informed when management or other important arrangements change?
This was an unannounced inspection focused on Safe and Well-led, prompted by concerns about risk management and leadership; infection prevention and control was also examined. This explanation was written from the published report of 1 September 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.
What inspectors found, February 2022
Cathedral Care Centre was inspected but not rated; inspectors found strong infection controls, but the COVID-19 policy needed more detail and one relative was not fully aware of essential caregiver visits.
This was a targeted inspection on 20 January 2022. It focused on infection prevention and control during the COVID-19 pandemic. The inspection was announced 18 hours in advance.
Inspectors found robust visiting arrangements, effective use of personal protective equipment, regular cleaning and systems for testing, vaccination, isolation and managing outbreaks. They were assured that the home was meeting the main infection control requirements.
There were two points to improve. The infection prevention and control policy did not contain enough detail about COVID-19. One relative was not fully aware that they could act as an essential caregiver, and the manager said this would be explained again.
The home was inspected but not rated. This report does not give a full quality rating for the home or ratings for most areas of care.
Infection control
The home was clean and hygienic, with regular cleaning of high-touch areas and correct PPE used during the inspection.
“The service was clean and hygienic and infection prevention and control, best practice guidance was maintained.” from the report
Visiting arrangements
Visitors had to show a negative COVID-19 test and wear PPE. People were also supported to stay in contact with family through window, garden and telephone visits.
“Visiting procedures were robust to reduce the risk of COVID-19.” from the report
Outbreak planning
The home had COVID-19 risk assessments and contingency plans. It used isolation, grouping and zoning to help manage infection spread.
“COVID-19 related risk assessments had been completed, and contingency plans were in place to manage a COVID-19 outbreak.” from the report
Testing and vaccination
Staff and residents were supported to take part in COVID-19 testing and vaccination programmes. The home met the requirement for non-exempt staff and visiting professionals to be vaccinated.
“People had been supported to participate in the COVID-19 testing programme and vaccination programme.” from the report
Policy detail
needs fixingThe infection prevention and control policy did not contain enough detail about COVID-19. The manager said it would be reviewed.
“The registered manager told us they would review the infection prevention and control policy, which we found did not contain enough detail about COVID-19.” from the report
Essential caregiver information
minorOne relative was not fully aware of the essential caregiver option. The manager said this would be explained again to residents and relatives.
“At inspection we identified one relative who was not fully aware of this opportunity.” from the report
- 01What extra detail has now been added to the infection prevention and control policy about COVID-19?
- 02How are residents and relatives told about the essential caregiver role?
- 03How would you manage a COVID-19 outbreak now, including isolation, zoning and staffing pressures?
- 04How do you check that staff and visiting professionals meet the vaccination requirements?
- 05How can residents keep in contact with family if visiting restrictions are needed?
This was a targeted inspection of infection prevention and control, with questions about COVID-19-related staffing pressures; it was not a full inspection of the other care quality areas. This explanation was written from the published report of 25 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.
Every inspection of Cathedral Care Centre
4 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- September 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- January 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2019Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2018
Registered with the Care Quality Commission on 5 October 2018.
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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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.