CQC report explained · a nursing home
What the CQC found at Lister House Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that infection prevention and control measures were being followed, including screening, PPE, testing, cleaning and visiting arrangements.
- Effective?
- Good
- This question was not assessed in this targeted inspection.
- Caring?
- Good
- This question was not assessed in this targeted inspection.
- Responsive?
- Good
- This question was not assessed in this targeted inspection.
- Well-led?
- Requires improvement
- This question was not assessed as a separate question in this targeted inspection, although inspectors noted the manager promoted learning and improvement.
What inspectors found, February 2022
Inspected but not rated; inspectors found strong COVID-19 infection control arrangements and safe visiting.
This was a targeted, announced inspection on 17 February 2022. Inspectors gave the home 24 hours’ notice and checked infection prevention and control arrangements, including staffing pressures linked to COVID-19.
Inspectors were assured that the home was managing infection risks. Visitors were screened, the home was clean, communal areas were ventilated, and personal protective equipment and testing were being used.
The inspection looked only at infection prevention and control under the Safe question. The home was inspected but not rated, so this report does not give an overall quality rating.
Visitor screening
Visitors had to complete COVID-19 checks, have their temperature taken and show a negative lateral flow test. Visiting professionals’ vaccination status was also checked.
“A robust screening process was in place for all visitors.” from the report
Clean and ventilated home
Inspectors found the home clean, with enhanced cleaning schedules and ventilation in communal areas to help reduce infection risks.
“The home was clean and enhanced cleaning schedules were maintained.” from the report
Safe visiting
The home supported visiting in ways that considered people’s needs and preferences. It also provided a visitor pod in the grounds.
“Safe visiting was taking place with consideration of individual's needs and preferences.” from the report
Staff infection control training
Staff had recently completed refresher training on using PPE and washing their hands effectively.
“Staff had recently completed refresher training which included observations of doffing and donning PPE and effective hand washing.” from the report
Inspectors raised no specific concerns in this report.
- 01How are visitors currently screened and what infection control checks are still in place?
- 02How do you manage staffing pressures when staff are absent because of COVID-19?
- 03How often are staff trained and observed in using PPE and washing their hands?
- 04How do you support visits for people whose needs or preferences make ordinary visiting difficult?
- 05When was the home last assessed on care quality areas other than infection prevention and control?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; the service was inspected but not rated and the other questions were not assessed. This explanation was written from the published report of 26 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, February 2019
Rated Good overall; inspectors found safe, kind and responsive care, but the home required improvement in how it was managed and checked.
Inspectors made an unannounced visit on 15 January 2019. They spoke with people living in the home, relatives and staff, observed care, and checked care plans, medicines, recruitment, training and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found enough staff, safe medicines systems, suitable training, detailed care plans, good support with food and healthcare, and kind care that respected people's dignity.
The Well-led rating was Requires Improvement. The manager had only recently started and was applying to register with CQC. Quality checks had missed some staff-file documents and the fact that not all staff had completed a fire drill in the previous 12 months.
The overall rating improved from Requires Improvement at the previous inspection, published in February 2018. Inspectors found that improvements had been made, but said further checks were needed to make sure these improvements were maintained.
Safe medicines
Medicines were administered by nurses and stored securely. Inspectors found that the new computerised system helped medicines to be managed safely.
“This system was effective in ensuring medicines were administered correctly and managed safely.” from the report
Kind and dignified care
Staff knew people well, explained what they were doing and treated people with dignity. Inspectors saw staff checking on people and responding calmly and patiently.
“Staff were caring and kind to people.” from the report
Personalised support
Care plans recorded people's likes, dislikes, communication needs and what mattered to them. Staff could explain how they supported people according to this information.
“People's likes, dislikes and what was important to the person were recorded in person centred care plans.” from the report
Staffing and training
Inspectors found enough staff to meet people's needs and saw that recruitment checks were completed. Staff received training, supervision and additional training where needed.
“There were enough staff on duty to support the needs of people and keep them safe.” from the report
Quality checks missed issues
needs fixingThe home's audits had not found some missing documents in staff files or that not all staff had completed a fire drill in the previous year. The manager sent CQC an action plan and inspectors recommended adding further audits.
“some missing documentation in staff files and not all of the staff had completed a fire drill in the last 12 months.” from the report
New manager still registering
needs fixingThe manager had been in post for only a few weeks and was in the early stages of applying to register with CQC. This contributed to the Requires Improvement rating for Well-led.
“The manager had only been in post for a few weeks at the time of the inspection.” from the report
- 01Has the manager now completed their application to register with CQC?
- 02What additional audits were introduced to check staff files and fire-drill training?
- 03Have all staff completed a fire drill, and how often is this training now checked?
- 04How are medicines monitored now that the computerised medicines management system is in use?
- 05How are people's changing preferences, communication needs and healthcare needs recorded and reviewed?
This was a planned, unannounced inspection covering all five CQC questions, including care, the premises and how the home was managed. This explanation was written from the published report of 23 February 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 Lister House Nursing Home
6 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- February 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2018Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2017Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: InadequateResponsive: Requires improvementWell-led: Inadequate
- May 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2015Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 12 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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