CQC report explained · a nursing home
What the CQC found at Community of St Mary at the Cross
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People and families said the home was safe, and staff understood safeguarding and risk procedures. Inspectors found some gaps in care records and issues with medicines documentation and staff competencies.
- Effective?
- Good
- This key question was not inspected during this focused inspection. Its rating was carried over from the previous inspection when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused inspection. Its rating was carried over from the previous inspection when calculating the overall rating.
- Responsive?
- Good
- Care plans reflected people's needs, preferences, life histories and goals. Communication needs were supported, complaints were investigated, and people were offered activities, although some people wanted more to do.
- Well-led?
- Good
- The home had quality checks, feedback systems and an open culture. However, some medicine issues had not been identified by audits, and people and staff gave mixed views about recent changes.
What inspectors found, January 2024
Henry Nihill House was rated Good; inspectors found safe, person-centred care, but identified gaps in medicines records and some care plans.
This was an unannounced focused inspection on 23 November 2023. Four inspectors visited, including two who focused on medicines. They spoke with people, relatives, staff and managers, and reviewed care plans, risk plans, medicine records and management documents.
The home was rated Good overall. Safe, Responsive and Well-led were also rated Good. Inspectors found people felt safe, staff were recruited safely, the home was clean, and care was generally personalised and responsive.
There were some shortfalls. One care plan was missing for an identified need. Some medicines documentation was out of date and some staff medicine competencies were not current. Some people wanted more activities, and there were mixed views about recent management and staffing changes.
This was a focused inspection covering Safe, Responsive and Well-led. The other two areas were not inspected at this visit, so the overall rating used ratings from the previous inspection.
People felt safe
People told inspectors they felt safe. Safeguarding concerns had been reported, investigated and monitored by senior managers.
“People told us they felt safe in the home, comments included, "I feel safe in the home” from the report
Safe staffing and recruitment
Inspectors found enough suitable staff on duty and evidence of safe recruitment checks. Staff were observed responding to people and call bells.
“The provider ensured there were enough suitable staff on duty to meet people's needs and staff were recruited safely.” from the report
Personalised care
Care plans included people's preferences, life histories, abilities and goals. Families and people were involved in developing their care.
“Care plans reviewed showed evidence of families and people being involved in their development.” from the report
Communication and end-of-life support
The home assessed communication needs and used different formats. End-of-life wishes, including religious beliefs, were recorded and support was arranged with health professionals.
“People's communication needs were assessed, and information was provided in different formats, for example the complaints procedure was both in pictures and words.” from the report
Clean home and infection control
The home was clean and maintained. Staff used protective equipment, followed cleaning schedules and had infection prevention training.
“During our visit we observed staff cleaning and sanitising areas within the home.” from the report
Medicine records and staff checks
needs fixingSome 'as and when needed' medicine documentation was out of date, and some staff competency checks were not current. The inspector recommended getting advice about staff competencies and record keeping.
“Medicines were mostly managed safely. However, we found some issues such as out of date documentation for 'as and when medicine' and some staff competencies were not up to date.” from the report
A missing care plan
needs fixingOne record did not contain a care plan for an identified need. The manager said all care plans would be reviewed and updated immediately.
“However, we found there were some gaps in information in some records we reviewed.” from the report
Activities
minorSome people said they did not have enough activities. The manager said this would be addressed after the inspection.
“Some people told us they did not have enough activities to do.” from the report
Recent management changes
minorThe home was going through a period of adjustment after management and staffing changes. Most people and staff were supportive, but some gave mixed views or raised concerns.
“Some people and staff gave us mixed reviews about the management of the service.” from the report
- 01What has been changed to keep 'as and when needed' medicine records up to date?
- 02How do you check that every staff member who gives medicines remains competent?
- 03Was the missing care plan completed, and how do you check that care plans cover every identified need?
- 04How are activities matched to each person's interests, including people who do not join group activities?
- 05What has been done to support staff and residents through the recent management and staffing changes?
This was an unannounced focused inspection of Safe, Responsive and Well-led only; Effective and Caring were not inspected and the overall rating used previous ratings for those areas. This explanation was written from the published report of 23 January 2024 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 2018
Community of St Mary at the Cross was rated Good; inspectors found kind, personalised care and particularly strong end-of-life support.
The inspection was unannounced and took place on 19 July 2018. Inspectors spoke with people living at the home, relatives, staff and health professionals. They reviewed care records, medicine records, recruitment files, training records, complaints, meetings and the building.
The home received Good ratings for Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people felt safe, staff were kind and respectful, medicines were managed safely, and care records were detailed and up to date.
The home provided a wide range of activities and trips out. Inspectors found particularly strong end-of-life care, supported by close working with health professionals. The home also had quality checks and an improvement plan in place.
A previous inspection in 2015 found a breach about how the service was governed. A focused inspection in 2016 found improvements, and the home was no longer in breach. The 2018 inspection found the service remained Good overall.
Kind and respectful staff
People and relatives consistently praised staff for being caring, patient and respectful. Inspectors also observed staff treating people with dignity.
“People and their relatives told us they were treated with dignity and respect.” from the report
Personalised care
Care records described people's needs, preferences and communication in detail. Staff were given clear guidance about how to support each person.
“Care records were up to date, comprehensive and gave a holistic view of people's needs and their preferences for care.” from the report
End-of-life support
The home worked closely with the local hospice, GP and other health professionals. Plans included personal wishes, such as preferred music and staying well groomed.
“This was considered innovative and best practice for this area of care.” from the report
Activities and outings
People could take part in crafts, quizzes, music and community activities. The home also arranged trips, including visits to the seaside.
“There was a comprehensive programme of activities at the service, these were displayed on a large activities board.” from the report
Quality checks
The management team checked medicines, care records, hygiene, the environment, food and night-time care. The findings were linked to an improvement plan.
“There were effective auditing systems in place and a service improvement plan to ensure actions to improve quality were progressed.” from the report
Recent staffing changes
minorOne person mentioned recent changes and felt staff were overworked. Inspectors also found enough staff during the visit and saw people receiving care calmly.
“Lot of changes recently. I think they are overworked, they work very hard.” from the report
- 01One person mentioned recent staffing changes and staff being overworked. What staffing changes have happened since the inspection?
- 02How do you make sure there are enough familiar staff to support my relative throughout the day and night?
- 03How are personalised end-of-life plans made, reviewed and shared with relatives and health professionals?
- 04The home planned to apply for Gold Standards Framework accreditation in 2019. What was the outcome of that plan?
- 05How are relatives involved in meetings and decisions about the home and their family member's care?
This was an unannounced comprehensive inspection covering all five CQC questions; it also followed up improvements to the governance breach found in 2015. This explanation was written from the published report of 17 November 2018 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 Community of St Mary at the Cross
4 rated inspections over 8 years: the service has held its Good rating throughout.
- January 2024Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Community of St Mary at the Cross →
- November 2018Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Community of St Mary at the Cross →
- June 2016Goodstayed GoodWell-led: Good
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 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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