CQC report explained · a nursing home
What the CQC found at St Andrew's Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm. Medicines, staffing, recruitment, risk assessments and safety checks were found to be effective, although the monitoring of accidents, incidents and falls needed improvement.
- Effective?
- Good
- People's outcomes were consistently good. Staff had relevant training, care assessments were detailed, people's nutrition and healthcare needs were supported, and mental capacity procedures were followed.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Well-led?
- Requires improvement
- The home had quality and safety checks, and people and staff spoke positively about the management. However, action records and handover records were not always reliable or joined up.
What inspectors found, May 2023
Rated Good overall; inspectors found safe and effective care, but well-led remained Requires Improvement because records were not always complete.
This was an unannounced focused inspection on 17 April 2023. One inspector and an Expert by Experience spoke with people, a relative and staff. They reviewed care and medicine records, staff files, audits and policies, and looked around the home.
The home was rated Good overall. Safe and Effective were both rated Good. Inspectors found safe medicine practice, enough staff, regular safety checks, suitable training and care plans that reflected people's needs. People said they felt safe and well looked after, and staff treated people with dignity and respect.
Well-led was rated Requires Improvement. Quality systems were in place, but records were not always completed effectively. Handover records did not always show the actions needed, and systems for recording follow-up actions were disjointed. The provider was no longer in breach of regulations found at the previous inspection.
Safe medicines
Medicines were received, stored, given and disposed of safely. Staff were trained and their competence was checked.
“Medicines were safely received, stored, administered and destroyed if they were no longer required.” from the report
Suitable staffing
Inspectors found enough staff on each shift, and recruitment checks were completed before staff started work.
“There were enough staff on duty each shift to safely support people.” from the report
Person-centred care
Care plans included people's needs, preferences, social history and important personal information. People were treated respectfully.
“Care plans were person-centred and included social and cultural care information on people's social history, preferences and things that were important to them.” from the report
Improved legal practice
Mental capacity assessments and best-interest decisions had improved since the previous inspection, with relatives or advocates involved where appropriate.
“Best interest decisions had been made with the involvement of others such as relatives and or advocates.” from the report
Positive atmosphere
People and staff described the management positively. Inspectors saw a warm and supportive atmosphere.
“St Andrews Court was welcoming, and the atmosphere was warm and supportive.” from the report
Incomplete records
needs fixingRecords did not always show important information about people's current needs. Handover records and action records were not consistently clear or joined up.
“However, systems used to record actions were disjointed.” from the report
Handover information
needs fixingHandover records did not always record what staff needed to do or what had been completed. The provider was asked to develop a better recording system.
“handover records did not always capture actions needed and completed to ensure staff understood peoples most current needs.” from the report
Monitoring accidents and falls
needs fixingThe home recorded incidents and accidents, but there was little evidence that it was analysing them to identify patterns and learn lessons.
“However, there was minimal evidence to support the monitoring and analysing of accidents, incidents or falls.” from the report
Areas needing refurbishment
minorInspectors were only somewhat assured about some aspects of infection prevention because parts of the home needed refurbishment to make cleaning more effective.
“Some areas of the care home required refurbishment to enable more effective cleaning.” from the report
- 01What changes have you made to handover records so staff always know people's most current needs?
- 02How are you now analysing accidents, incidents and falls, and how do you use the results to prevent them happening again?
- 03How do you track actions from audits and make sure they are completed?
- 04Which areas need refurbishment to improve cleaning, and when will this work be completed?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were used to calculate the overall rating. This explanation was written from the published report of 17 May 2023 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, January 2022
Rated Requires Improvement; inspectors found kind, personalised care but serious gaps in medicines, fire safety, staff training and oversight.
This was the home’s first inspection. Three inspectors visited without notice on 02 December 2021 and 08 December 2021. They spoke with people, relatives, staff and other professionals, and checked care, medicines, staff records and management records.
People were generally treated kindly and respectfully. Care plans were personalised and up to date. People had access to activities, healthcare support and suitable food. The home was clean, infection control measures were in place, and staffing levels were suitable.
However, inspectors found important safety problems. Medicines records were incomplete, fire safety actions had not been finished, and accidents and falls were not properly analysed. Some staff lacked required training, and records did not always show that decisions about capacity and consent followed the law.
The overall rating was Requires Improvement. Safe, Effective and Well-led were also rated Requires Improvement. Caring and Responsive were rated Good. This means some parts of care were working well, but there was limited assurance about safety and management.
Kind and respectful care
People and relatives described staff as kind, respectful and supportive. Inspectors also saw patient and positive interactions.
“People and their relatives confirmed they were treated in a kind, respectful and supportive way.” from the report
Personalised care
Care plans reflected people's needs, preferences, communication needs and interests. Staff knew people well and supported their independence.
“Staff developed personalised care plans that accurately reflected people's needs and preferences.” from the report
Activities and relationships
People were offered social activities and support to maintain contact with family and friends. The home also helped people pursue individual interests.
“People were encouraged to develop activities that interested them.” from the report
Infection control
Inspectors were assured that the home had measures for infection prevention, testing, protective equipment, visits and managing outbreaks.
“We were assured the provider was using PPE effectively and safely.” from the report
Safe recruitment and staffing levels
Staff had pre-employment checks, and inspectors found enough staff were on duty. Extra staffing could be considered when someone needed more support.
“Staffing levels remained suitable and the option to increase staffing in specific circumstances was considered” from the report
Medicines records
seriousRecords did not always explain when or why as-required medicines were given. There was also no clear record of who applied creams, or proof that all staff had up-to-date medicines checks.
“Medicines were not always managed safely.” from the report
Fire safety
seriousUrgent actions from a fire risk assessment had not been completed. Staff had no evidence of training in evacuation equipment, and some fire drills took much longer than the stated three-minute target.
“Urgent recommendations from an independent fire risk assessment provider in February 2021 to ensure the service was safe had not been completed at the time of our inspection” from the report
Staff training
seriousA significant number of staff had not completed positive behaviour support training, despite some people having complex needs. Staff also showed gaps in their understanding of consent and the Mental Capacity Act.
“A significant number of staff had not completed positive behaviour support training.” from the report
Capacity and consent records
needs fixingRecords did not show that mental capacity assessments and best-interest decisions had always been completed properly. There were also no records showing how consent had been sought for some COVID-19 tests.
“There was a lack of information in records to show mental capacity assessments and best interest meetings had been completed in accordance with the MCA.” from the report
Weak management checks
seriousAudits and action plans did not reliably identify or fix problems. Incidents, falls and accidents were not analysed well enough to reduce the chance of them happening again.
“An effective system was not operated to monitor the quality and safety of the service.” from the report
- 01What has been completed to improve medicines records, including records for as-required medicines and creams?
- 02Have all urgent actions from the fire risk assessment been completed, and how quickly can the home now evacuate people?
- 03Which staff have completed positive behaviour support training, and what training is still outstanding?
- 04How are mental capacity assessments, best-interest decisions and consent records now checked?
- 05How are falls, accidents and incidents analysed and followed up to prevent them happening again?
This was an unannounced planned comprehensive inspection covering all five key questions, including infection prevention and control. This explanation was written from the published report of 15 January 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.
Every inspection of St Andrew's Court
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- May 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2022Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- October 2019
Registered with the Care Quality Commission on 23 October 2019.
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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Most charge £1,020 to £1,350 a week. 12 can care for a couple. 8 years' experience on average.
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