CQC report explained · a residential care home
What the CQC found at St Annes Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2021
Rated Requires Improvement; inspectors found infection risks, poor person-centred support and inadequate leadership, although staff were kind and safety arrangements were in place.
This was an unannounced focused inspection on 30 June and 1 July 2021. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicines, staffing and management records.
The home was not always clean, and some COVID-19 safety measures were missing. People were not always supported with their communication needs, personal choices or cultural food preferences. The home’s audits had failed to find problems, and improvements from earlier inspections had not been sustained.
There were also positive findings. Staff were described as kind and respectful. Inspectors found enough trained staff, safe medicines support, safeguarding knowledge and suitable responses to accidents. The new manager had started making changes, but inspectors needed more time to see whether these would last.
The overall rating stayed at Requires Improvement. Safe and Responsive were rated Requires Improvement, while Well-led fell to Inadequate. The home had received Requires Improvement at six consecutive inspections.
Kind and respectful staff
People and relatives gave positive feedback about staff kindness. Staff knew people well and spoke to them respectfully.
“Staff treated people with kindness and respect and knew them well.” from the report
Enough staff
People, relatives and staff said there were enough staff. Inspectors saw staff respond to people’s needs and call bells promptly.
“During the inspection, staff were able to attend to people's needs as and when required.” from the report
Medicines support
People had detailed medicines plans. Staff were trained and had their competence checked.
“People were supported to take their medicines safely.” from the report
End of life care
Inspectors found compassionate end of life support, with detailed plans about people’s wishes and work with health professionals.
“People received kind and compassionate care at the end of their life.” from the report
Cleanliness and infection control
seriousSeveral areas were dirty and some furniture could not be cleaned easily. Visitor screening and hand sanitiser arrangements were not sufficient at the inspection.
“Several areas of the service were visibly dirty and in need of cleaning.” from the report
Communication and personal choices
seriousInformation was not provided in suitable formats for people with communication needs. Personal, cultural and dietary preferences were not always met.
“People were not being supported to communicate in line with the Accessible Information Standard and people's personal preferences were not being met.” from the report
Weak quality checks
seriousThe home’s audits did not identify repeated problems. Inspectors were not assured that the provider could make and sustain improvements.
“The provider has been unable to implement and sustain improvements over multiple inspections.” from the report
Limited activities and interaction
needs fixingActivities had become less frequent after the activities coordinator left. People spending time in their rooms could go for longer periods without significant interaction.
“People who spent time in their rooms went for longer periods without significant interaction” from the report
- 01What has been done to clean the areas identified as dirty, and how are cleaning records now checked?
- 02What COVID-19 screening, PPE station and hand sanitiser arrangements are currently in place for visitors and staff?
- 03How do you support residents with dementia or other communication needs to understand information and make complaints?
- 04How are cultural food choices, personal preferences and the needs of people who spend time in their bedrooms recorded and checked?
- 05What evidence can you show that the new audits and improvement plans are working and will be sustained?
This was a focused inspection of Safe, Responsive and Well-led; the Effective and Caring ratings were not assessed and previous ratings were carried forward. This explanation was written from the published report of 30 September 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, March 2020
Crowley Care Homes Ltd - St Annes Care Home was rated Requires Improvement; inspectors found kind care and safe medicines, but gaps in risk management, responsiveness and leadership remained.
This was an unannounced inspection on 30 January 2020. Two inspectors observed care, spoke with people, relatives, staff and visiting professionals, and checked care records, medicines records, accidents and quality checks.
The home was rated Good for Effective and Caring. People were treated with kindness and dignity, involved in their care, supported to make choices and helped to access healthcare. Medicines were administered safely, and activities and community links had improved.
The overall rating was Requires Improvement because some risks were not properly assessed, staff did not always respond quickly when people asked for help, and management checks did not find all the problems. The home had improved since the previous inspection and was no longer in breach of the two regulations identified previously, but more work was needed.
Safe medicines
Medicines were given as prescribed. Staff were trained and checked as competent, and audits and stock checks were in place.
“People received their medicines safely and as prescribed.” from the report
Improved activities
The home provided more regular activities and supported people to attend community groups. Staff also offered activities to someone who was cared for in bed.
“There were regular activities offered to people and weekly visiting entertainers.” from the report
Staff development
The home had increased training, supervision and mentoring. Some staff were undertaking more detailed training in areas including dementia, challenging behaviour and end-of-life care.
“Since the last inspection there was a focus on developing staff skills and understanding of their role.” from the report
Unassessed care risks
seriousOne person with a catheter did not have a care plan or risk assessment to guide staff. A pressure-relieving mattress was also set incorrectly and there were no records to show that its setting had been monitored.
“one person who had a catheter in place had no care plan or risk assessment to guide staff on how to support them with this.” from the report
Delayed response to distress
seriousStaff did not always respond promptly when people asked for help. One person with itchy, bleeding skin needed an inspector to draw staff's attention to the problem and prompt them further.
“Staff standing close by did not respond until an inspector drew their attention to the person, and then required further prompting from the inspector to fully meet their needs.” from the report
Premises and infection risk
needs fixingChipped paintwork and damaged or soiled furniture created a possible infection control risk. Construction and refurbishment work was under way, and some areas still needed redecoration or replacement.
“There was a risk of the spread of infection due to chipped paintwork and damaged or soiled furniture in some parts of the service.” from the report
Limited dietary choice
needs fixingFour vegetarian people did not always have a suitable meal choice from the menu. The report found no evidence of harm and said their weights were stable, but recommended that dietary practice be improved.
“there was no evidence that they were offered a varied and healthy diet overall.” from the report
Weak management oversight
needs fixingThe registered manager did not have enough oversight to lead effectively. Responsibilities for following up weight loss were unclear, and the quality audit system still needed further development.
“We found the registered manager did not have strong enough management oversight of the service to enable them to lead effectively.” from the report
- 01How do you now check that pressure-relieving mattresses are set correctly and that these checks are recorded?
- 02How do staff identify and assess risks for people with catheters or other specific care needs?
- 03What changes have been made to ensure staff respond quickly when people ask for help?
- 04What vegetarian and other special-diet choices are now available, and how do you check that meals are varied and healthy?
- 05What changes were made to the management structure and quality audits after this inspection?
This was an unannounced inspection of the care and premises across all five CQC questions, with the previous ratings considered because the inspection followed an earlier Requires Improvement rating. This explanation was written from the published report of 11 March 2020 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 St Annes Care Home
6 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- September 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- March 2020Requires improvementstayed Requires improvementSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Requires improvement
- July 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2016Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- September 2011
Registered with the Care Quality Commission on 21 September 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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