CQC report explained · a residential care home
What the CQC found at St Ann's Lodge 1
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2023
Rated Requires Improvement; inspectors found unsafe medicines records and weak checks, although people received kind, personalised support.
Inspectors visited on 6 December 2022. They spoke with three people, six staff members and a healthcare professional. They reviewed care files, recruitment files, medicines records, incidents and accidents, and quality checks.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. Medicines were not always recorded properly, and protocols for medicines given when needed were not always clear. Some incidents and accidents were not recorded on the correct forms.
Inspectors also found enough staff, suitable recruitment checks, good infection control and staff who knew people well. People were supported to make choices, build independence and take part in activities.
The previous rating was Good, published in November 2017. This inspection changed the overall rating to Requires Improvement. The provider sent updated records after the inspection, but CQC said it would continue to monitor progress.
Enough staff
Inspectors found enough staff to provide care and one-to-one support when people wanted activities or visits.
“People and staff confirmed staffing levels were sufficient to ensure people could receive care and support when they wanted.” from the report
Staff knew people well
Staff understood people's communication, behaviour and support needs. They used least restrictive ways to help people stay safe when anxious or distressed.
“People continued to receive support from staff that knew them well and how to safely respond to them” from the report
Choice and independence
People were supported to express their views, try new experiences, develop skills and become more independent.
“People had the opportunity to try new experiences, develop new skills and gain independence.” from the report
Infection control
Inspectors were assured that the home used infection control measures, including safe use of protective equipment and arrangements for visitors.
“We were assured that the provider was using PPE effectively and safely.” from the report
Medicines records
seriousSome medicines given when needed were not listed or recorded on medicines administration records. Inspectors said this created a risk that people might not receive medicines as prescribed.
“People were given medicines that were not always recorded on a medicines administration record (MAR).” from the report
Medicines protocols
seriousInstructions were not always clear enough for staff about when to give medicines prescribed for use when needed.
“People did not always receive their medicines safely.” from the report
Incident recording
needs fixingSome incidents and accidents were not recorded on the correct forms. Inspectors recommended that the recording systems be reviewed.
“Not all incidents and accidents were clearly recorded on the appropriate recording systems.” from the report
Weak quality checks
needs fixingThe manager's audits did not identify the problems found during the inspection. Some checks used general yes-or-no answers and did not clearly show which records had been reviewed.
“We also identified audits were simplistic with generic yes and no answers.” from the report
- 01What changes have been made to ensure every medicine given when needed has a clear protocol and is recorded on the medicines administration record?
- 02How do you now check that medicines records are complete and accurate?
- 03How are incidents and accidents recorded, reviewed and used to prevent similar events?
- 04What changes have been made to the quality audits, and can you show recent audit results?
- 05What evidence can you provide that the issues identified after this inspection have been fully addressed?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other key-question ratings were not inspected and were carried forward from the previous inspection. This explanation was written from the published report of 20 January 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, November 2017
Rated Good; inspectors found safe, kind and personalised care, with accessible support documents still being completed for everyone.
Inspectors visited on 13 September and 13 October 2017. The first visit was unannounced. They spoke with four people, staff, managers, relatives and external health professionals, and checked care records, medicines, staffing, training, the building and management records.
The home supported up to six people with learning disabilities, and six people were living there during the inspection. Inspectors found enough staff, safe medicines procedures, suitable training and support for people's health, nutrition and choices. They also found warm relationships, personalised care and good support for activities, family contact and community life.
All five areas were rated Good: safe, effective, caring, responsive and well-led. This was the first inspection since changes to the home's CQC registration in October 2016, so the report does not describe a previous rating for comparison.
Staff knew people well
A consistent staff and management team understood people's needs, preferences and routines. This helped care remain personal and familiar.
“People received care and support from a long standing group of managers and staff who knew them very well and understood their needs and preferences.” from the report
Kind and respectful care
People and relatives described staff as caring. Inspectors saw warm relationships and found that privacy, dignity and people's choices were respected.
“Observed interactions between the registered manager, staff and the people who lived there were warm, friendly and familiar.” from the report
Active lives and family contact
People were supported to attend placements and clubs, go out, take holidays and maintain contact with relatives and friends.
“People were supported to be as independent as possible and to lead active lives by staff at St Ann's Lodge.” from the report
Safe medicines and staffing
Inspectors found enough staff for people's needs. Medicines were stored securely, given safely and recorded accurately.
“Medicines were securely stored and records of administration were up to date and accurate.” from the report
Good oversight
The home used audits and checks to monitor care, medicines, safety and incidents, with action taken when improvement was needed.
“Quality audits were used to monitor and improve the service and were effective in maintaining a high quality service.” from the report
Accessible documents still being completed
minorMuch of the care information was available in pictures and photographs, but the work to make all support documents accessible to everyone was still ongoing.
“The deputy manager told us that this work was on-going to make sure that all the support documentation was available in an accessible format for everybody using the service.” from the report
- 01How far has the work gone to make every person's support documentation accessible?
- 02How will you make sure staffing remains sufficient when people need one-to-one support, appointments or outings?
- 03How will you involve my relative in creating and reviewing their support plan?
- 04What activities, outings, family contact and community opportunities would be available for my relative?
- 05How are changes in my relative's health, needs or medicines recorded and shared with staff?
This was an inspection of all five CQC areas, following changes to the home's registration in October 2016; it was the first inspection since those changes. This explanation was written from the published report of 22 November 2017 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 Ann's Lodge 1
2 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- January 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2017GoodSafe: GoodWell-led: Good
- October 2016
Registered with the Care Quality Commission on 4 October 2016.
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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At least 100 live-in carers within about an hour of Kingston upon Thames
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 £980 to £1,260 a week. 82 can care for a couple. 11 years' experience on average.
“Without his support we wouldn't have been able to navigate bringing and keeping Dad at home.”
“We cannot speak highly enough of the care that Angelique gave, and would recommend her to anyone else needing a live-in carer.”
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.