CQC report explained · a nursing home
What the CQC found at St Peters Residence
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 2020
Inspected but not rated; inspectors found good infection-control arrangements during the coronavirus pandemic.
This was an announced, targeted inspection on 3 August 2020. Inspectors looked only at infection prevention and control measures as part of a coronavirus pandemic review.
They found good practice. The home was clean, visitors were given personal protective equipment, staff had infection-control training, and staff used protective equipment appropriately. The home also used isolation arrangements, social distancing and changes to communal spaces to reduce infection risks.
The home supported people to keep in touch with relatives and health professionals using video calls when visits were restricted. Staff rotas were managed to provide consistency, and two volunteers lived at the home during lockdown to give extra support.
The service was inspected but not rated. This means the report does not give a graded overall rating or a graded rating for safety.
Clean environment
Inspectors found the home very clean. Cleaning arrangements had been changed during the pandemic to reflect guidance and visiting arrangements.
“The home was spotlessly clean when we inspected.” from the report
Staff training and PPE
Staff received training about coronavirus, infection prevention and protective equipment. Inspectors saw staff using PPE appropriately.
“Staff received training in infection prevention and control and the use of PPE.” from the report
Managing isolation and risk
People could be supported in an isolated unit with a separate staff team when needed. New admissions were stopped during the height of the pandemic.
“When necessary to reduce the risk of cross-contamination, people were supported within an isolated unit with their own staff team.” from the report
Keeping people connected
When visits were restricted, people could use video calls to contact relatives and health professionals. Religious services were also streamed to bedrooms for a period.
“The provider ensured that people were able to keep in touch with their loved ones, and were able to be seen by relevant health professionals, through the use of video calling when visiting was restricted.” from the report
Inspectors raised no specific concerns in this report.
- 01What infection prevention and control arrangements are in place now?
- 02How are visitors currently given protective equipment, and what visiting rules apply?
- 03How would you isolate a resident or staff member if there was an infection risk?
- 04What testing arrangements are currently available for residents and staff?
- 05How would residents keep in touch with relatives and health professionals if visits were restricted?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; it did not assess the other four questions or provide a graded overall rating. This explanation was written from the published report of 3 September 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.
What inspectors found, April 2020
Rated Requires Improvement; inspectors found kind, personalised care, but medicines, fire safety and management checks were not always reliable.
This was an unannounced inspection on 02 March 2020. Inspectors spoke with people living at the home, a relative, staff and other professionals. They also reviewed records and information supplied by the provider.
The home was rated Requires Improvement overall. Safe and Well-led were also Requires Improvement. Inspectors found medicines were not always managed safely, fire evacuation checks did not show how people would be evacuated, and management audits had missed these problems.
Effective, Caring and Responsive were rated Good. People were supported with food, healthcare, their choices, privacy and dignity. Care was personalised, communication needs were considered, and activities were available.
The previous overall rating was Good, published on 16 August 2017. The provider breached Regulation 17 on good governance. CQC said it would continue monitoring the home and check progress at a future inspection.
Kind and respectful care
People and relatives spoke warmly about the care. Staff respected privacy and dignity and supported people to remain independent where possible.
“The staff are always kind and caring and my dignity is respected” from the report
Good food and healthcare support
People were supported to choose meals and have diets suited to their needs. Healthcare professionals were contacted when needed.
“People were well supported to access healthcare professionals and told us that doctors were called in a timely manner when they needed them.” from the report
Personalised care and activities
Care plans reflected people's routines, preferences and backgrounds. People could take part in activities such as poetry, exercise, gardening and creative arts.
“People received care that was individualised, with records reflecting people's preferences.” from the report
Clean home and appropriate incident response
The home was very clean and well maintained. Incidents and accidents were reported, investigated and recorded, with learning shared among staff.
“The home was extremely clean and well kept, with daily housekeeping staff to ensure hygiene was well maintained.” from the report
Medicines were not always managed safely
seriousTemperature checks for medicine rooms and fridges were missed on two units, and controlled drug audits were irregular on one unit. Two nurses could not clearly explain covert medicines.
“Medicines were not always managed in a safe way.” from the report
Fire safety checks were not sufficient
seriousFire drills recorded staff evacuation but not how residents were evacuated. The full fire risk assessment had not been completed for 10 years.
“The provider could not be assured that the evacuation procedures in place for people were effective.” from the report
Management checks missed important problems
seriousAudits did not identify medicine and fire safety shortfalls in a timely way. This led to a breach of Regulation 17 on good governance.
“Improvements were needed to ensure that management oversight of the service was robust.” from the report
Dementia-friendly design could be improved
needs fixingThe home lacked enough pictorial signs, memory boxes and room personalisation to help people with dementia find their way around.
“The environment was not as dementia friendly as it could be.” from the report
Some care records needed improvement
needs fixingEnd-of-life care information was not always easy to find or fully recorded. Some staff were also not up to date with moving and handling refresher training.
“Records in relation to end of life care needs were not always easily accessible” from the report
- 01What changes have you made to daily medicine room and fridge temperature checks?
- 02How do you now check that nurses understand and can safely administer covert medicines?
- 03When was the full fire risk assessment last completed, and what do fire drills now record about evacuating residents?
- 04How do your quality audits make sure medicine and fire safety problems are identified promptly?
- 05How are end-of-life care wishes recorded and made easy for staff to find?
This was an unannounced comprehensive inspection covering all five CQC questions, including the care and premises provided by the home. This explanation was written from the published report of 4 April 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 Peters Residence
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- September 2020Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- April 2020Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 16 November 2010.
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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