CQC report explained · a residential care home
What the CQC found at Santa Care
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2022
Santa Care was rated Requires Improvement; inspectors found unsafe repairs, poor cleanliness and care that was not always personal or choice-based.
This was an unannounced inspection on 26 October 2022. One inspector spoke with two people, observed care, checked records for all three people, reviewed medicines and staff files, and examined the home’s checks and audits. Feedback was also sought from relatives and healthcare professionals, but none was received.
The home had enough staff according to the rota, medicines were given safely, and people’s healthcare needs were met. Staff had training and said they felt supported. People were also involved in some care reviews and meetings.
However, the home needed deep cleaning and repairs. Some risks and care plans had not been reviewed or updated. Inspectors saw limited interaction with people, few activities and not enough support with choices and independence. The systems used to check quality had failed to identify these problems.
All five areas were rated Requires Improvement. The previous overall rating was Good, published in February 2018. The home was asked to provide an action plan, and the CQC said it would monitor progress.
Medicines
People received their medicines safely and as prescribed. Records were complete, staff were trained and medicines were stored securely.
“People received their medicines safely and as prescribed.” from the report
Staff checks and training
The staff files checked by inspectors contained the required recruitment checks. Staff received induction, supervision and training relevant to people’s needs.
“We saw evidence staff training was up to date and regularly refreshed.” from the report
Healthcare support
People’s medical needs were recorded and met. The home worked with healthcare professionals, including supporting one person with regular district nurse visits.
“People's healthcare needs were recorded and met.” from the report
Supportive staff culture
Staff said they enjoyed working at the home and felt supported by management. Inspectors found that the home worked with other agencies involved in people’s care.
“There was a good culture at the home and people were happy and liked living there.” from the report
Safety risks and cleanliness
seriousInspectors found a protruding internet connection, a nail in a radiator cover, broken fittings and poor cleanliness. These issues could have caused injury or increased the risk of infection.
“Apart from the kitchen, most of the home needed a thorough clean.” from the report
Limited choice and independence
seriousPeople were not always asked what they wanted to eat, drink or do. Inspectors saw little interaction, few activities and no support with everyday tasks during the visit.
“People were not always consulted and given choice.” from the report
Out-of-date care information
needs fixingSome risk assessments and care plans had not been updated when people’s circumstances changed. The provider sent evidence after the inspection that some records had been corrected.
“We could not be sure that information on people's care plans was always correct or up to date.” from the report
Weak quality checks
seriousThe home carried out audits, but these had not identified the problems inspectors found with cleanliness, repairs, risks and person-centred care.
“The provider's systems for monitoring the quality and safety of the service had not always been effective” from the report
Limited activities and outings
needs fixingPeople had little to occupy their time and outings were not always organised. The report says people could not go out spontaneously when another member of staff was needed.
“During our inspection, the only engagement for people was to watch TV.” from the report
- 01What repairs and deep cleaning identified after the inspection have been completed, and how are they checked now?
- 02How do you make sure risk assessments and care plans are reviewed promptly when someone’s circumstances change?
- 03How will you offer each person daily choices about food, drinks, activities and how they spend their time?
- 04What activities and outings are currently available, and can people go out without waiting for extra staff?
- 05What quality checks are now in place to identify problems with cleanliness, safety and person-centred care?
This unannounced inspection looked at all five key questions and included the premises and care, but feedback from relatives and healthcare professionals was not obtained. This explanation was written from the published report of 25 November 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, August 2021
Inspected but not rated; inspectors found strong COVID-19 infection controls, but not all staff had received a risk assessment.
This was an announced, targeted inspection on 18 March 2021. It looked at infection prevention and control during the COVID-19 pandemic. Three people were living at the home at the time.
Inspectors found good arrangements for using and disposing of personal protective equipment, testing staff and residents, social distancing, visitor safety and isolating people on separate floors. Staff worked in only one care setting, and the provider did not use agency staff.
Inspectors were only somewhat assured that clinically vulnerable people and others at higher risk were protected. They found that one of the five staff had received a COVID-19 staff risk assessment, and asked for further assurance.
The service was inspected but not rated. This report does not provide an overall rating of the home or ratings for the other areas of care.
PPE and infection control
Used PPE was disposed of safely to help prevent cross-contamination, following local procedures.
“Disposal of used PPE prevented cross-contamination and followed local protocols, in particular single use items.” from the report
Testing arrangements
Staff who developed COVID-19 symptoms were tested without delay, and managers and staff knew how to access testing kits.
“All care home workers had a Covid-19 test without delay once they became symptomatic of Covid-19 infection.” from the report
Safe isolation
The building allowed people to be separated onto different floors when needed. Outdoor and communal spaces were also used to support social distancing.
“The design, capacity and layout of the home allowed the safe isolation of people into separate floors.” from the report
Incomplete staff risk assessments
needs fixingInspectors found that only one of the five staff had received a COVID-19 risk assessment. They said further assurance was needed about protecting clinically vulnerable people and others at higher risk.
“We found one out of the five staff had received a Covid-19 staff risk assessment.” from the report
- 01Have all staff now received a COVID-19 risk assessment?
- 02How often are staff risk assessments reviewed and updated?
- 03How do you protect people who are clinically vulnerable or at higher risk?
- 04How do you make sure infection prevention and control arrangements remain up to date?
- 05What were the home's previous ratings, since this inspection was not rated?
This was a targeted inspection of infection prevention and control during the COVID-19 pandemic; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 19 August 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.
Every inspection of Santa Care
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- November 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2021Inspected but not ratedSafe: Inspected but not rated
- February 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 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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