CQC report explained · a residential care home
What the CQC found at St Andrews House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2024
Rated Inadequate and placed in special measures; inspectors found serious safety and management failures, although medicines, staffing and activities were better.
This was an unannounced focused inspection on 28 November 2023. Inspectors observed care, spoke with 8 people, a relative, staff and managers, and checked care plans, medicines records, quality checks and recruitment records.
The home was not safe. Inspectors found risks from exposed hot water pipes, blocked or affected fire exits, trip hazards, unsafe storage, contractors' tools and poor infection control. They also found that falls and other incidents were not always properly reviewed.
The home was rated Requires Improvement for Responsive. Care plans were being reviewed and people said they were involved in their care and activities, but some plans lacked important detail. Well-led was rated Inadequate because quality checks had repeatedly failed to identify and fix problems.
The overall rating changed from Requires Improvement to Inadequate. This was the fifth consecutive inspection where the provider had not shown it met the expected standards. The home was placed in special measures and the CQC said it would normally be re-inspected within 6 months.
Medicines
People received their medicines as prescribed. Staff were trained and checked as competent before giving medicines.
“Staff members were trained and assessed as competent before supporting people with their medicines.” from the report
Staffing and recruitment
Inspectors found enough staff to respond to people in a timely way, with agency staff used when needed. Recruitment checks were completed.
“People were supported by enough staff to respond to them in a timely way.” from the report
Protection from abuse
Staff had been trained to recognise abuse and knew how to report concerns to the appropriate agencies.
“People were protected from the risk of abuse and ill treatment as staff members had received training on” from the report
Activities and relationships
People said they were involved in activities most days. The home encouraged visitors and provided space for private visits.
“There's quite a lot, something every day, they are usually in the afternoons.” from the report
Serious environmental and fire risks
seriousInspectors found exposed hot water pipes, unsafe access to heating systems, blocked or affected fire exits, trip hazards and unsafe storage. These problems put people at risk of burns, scalds, falls, fire-related harm and injury.
“A mechanical hoist was stored on the first floor in front of a fire escape blocking effective exit from this area.” from the report
Infection control and food storage
seriousCleaning was not consistently effective. Food was stored in a fridge that was above the safe temperature on two occasions, and some clinical waste bins lacked suitable internal bags.
“On 2 separate occasions we saw the temperature in this fridge was above the safe storage of food items, putting people at the risk of illness from bacterial growth.” from the report
Incidents were not fully reviewed
seriousA fall involving injury had not been fully monitored afterwards. This meant complications might not have been identified quickly.
“We saw 1 incident where a person had fallen and received injuries. However, the post falls monitoring processes had not been fully completed and there were gaps in the monitoring.” from the report
Weak quality checks
seriousThe provider's monitoring systems repeatedly failed to identify and correct risks. New systems had not been fully implemented or checked to confirm they worked.
“The quality monitoring systems continued to be ineffective in identifying concerns and driving improvements at St Andrews House.” from the report
Care plans still being improved
needs fixingCare plan reviews were under way, but at least one plan did not clearly say where lifting supports were located. This could make it harder for staff to provide consistent care.
“We noted a lack of consistent detail with 1 care plan where information concerning the location of lifting supports was not detailed.” from the report
- 01Have all exposed hot water pipes, unsafe hot taps, fire exit obstructions, fire doors and trip hazards now been fixed?
- 02How are you checking that food is stored at safe temperatures and that cleaning and clinical waste procedures are followed every day?
- 03What new process ensures every fall or accident is fully monitored and reviewed for lessons?
- 04Who is now responsible for maintenance and environmental safety, and how are trustees checking that actions are completed?
- 05Which care plans are still being reviewed, and how will you ensure lifting equipment and other important support details are clear?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried forward, although those ratings are not stated in the report text. This explanation was written from the published report of 19 January 2024 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 2023
St Andrews House is rated Requires Improvement, remains in special measures, and inspectors found serious weaknesses in safety and leadership.
This was an unannounced focused inspection on 12 and 14 June 2023. Inspectors spoke with 10 people living at the home, three relatives and nine staff. They also checked care records, medicines records, staff recruitment files, training information and management checks.
The home was not always safe. Inspectors found continuing fire safety and other environmental risks, incomplete care records, gaps in staff training, unsafe medicines processes and infection control practices that did not always follow guidance. Some people also said they had waited a long time for help after using their call bells.
People generally felt safe and staff recruitment had improved. Complaints were handled, people could access health professionals and most people were involved in care planning. However, activities outside the home were not available to everyone, and some people did not feel fully in control of their care.
The overall rating changed from Inadequate to Requires Improvement because some areas improved, but the well-led rating stayed Inadequate. This was the fourth consecutive inspection where the provider had not shown that required improvements were fully in place. The home remains in special measures.
Safeguarding
People told inspectors they felt safe. Staff understood how to recognise and report possible abuse, and the provider was no longer in breach of the safeguarding regulation.
“People were protected from the risk of abuse. The provider had policies and processes in place to identify and respond to safeguarding concerns.” from the report
Recruitment
The provider had improved recruitment arrangements and completed the required checks for permanent and agency staff.
“The provider completed the required pre-employment checks to ensure staff were suitable to work with vulnerable people.” from the report
Handling complaints
The home recorded complaints, investigated them and gave responses within appropriate timescales. Information about how to complain was displayed.
“We found the registered manager had systems to record and respond to complaints or concerns, ensuring further investigation was completed and resolutions sought to avoid reoccurrence.” from the report
Mental capacity
Inspectors found that people were supported under the Mental Capacity Act, with the required legal authorisations in place where needed.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.” from the report
Fire and environmental safety
seriousInspectors found a missing ceiling tile next to a fire door, an unsecured tap and water above the recommended safe temperature. A repeated falls risk had also not been addressed.
“Fire safety risks continued to be present at the service. For example, we found a ceiling tile located next to an adjoining fire door was missing.” from the report
Medicines safety
seriousSome prescribed creams were not clearly labelled. They were sometimes applied by staff without the required training or checks, and records did not always show that they had been given.
“Prescribed creams were being applied by staff who had not received medicines training or competency assessments.” from the report
Infection control
seriousUsed protective equipment was found in general waste bins, including one that remained uncleared two days after inspectors raised the issue. Staff also wore jewellery and watches against the provider's policy and guidance.
“We were not assured the provider was using and disposing of personal protective equipment effectively and safely.” from the report
Choice and activities
needs fixingSome people did not feel fully in control of their care. People who lacked regular family support were not always able to take part in activities outside the home.
“Activities outside of the home were not taking place for people who did not have regular informal support from their families.” from the report
- 01What has been done to correct the fire door, hot water and other environmental risks identified by inspectors?
- 02How do you now check that medicines, including prescribed creams, are applied only by trained and competent staff and recorded correctly?
- 03How are used protective equipment and staff jewellery now managed to prevent infection risks?
- 04How do you record and monitor call bell response times, and what has changed for people who previously waited a long time?
- 05What evidence can you show that care plans are being updated when people's needs change and that the provider's audits now identify problems promptly?
This was a focused inspection of Safe, Responsive and Well-led only; the Effective and Caring ratings were carried over from the previous inspection when calculating the overall rating. This explanation was written from the published report of 23 August 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.
Every inspection of St Andrews House
7 rated inspections over 9 years: the service has slipped, from Good to Inadequate.
- January 2024Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2023Requires improvementup from InadequateSafe: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2022Inadequatedown from Requires improvementSafe: InadequateResponsive: Requires improvementWell-led: Inadequate
- September 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- February 2020Requires improvementdown from GoodSafe: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2017Goodstayed GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- March 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Coventry
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £950 to £1,260 a week. 80 can care for a couple. 11 years' experience on average.
“If you bump into her in the night on her way to the bathroom she will still inquire how you are and if everything is alright.”
“My mum would not eat, drink, bath nor sleep without her. In short, she was FAMILY and we loved her dearly”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.