CQC report explained · a nursing home
What the CQC found at St Anne's Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2022
St Anne's Nursing Home was rated Good overall, but Well-led Requires Improvement after inspectors found weaknesses in oversight and reporting.
This was a focused inspection prompted by concerns about medicines and safeguarding. Inspectors visited on 23 November, 29 November and 20 December 2021. The first visit was unannounced.
The home was rated Good for Safe. Inspectors found that medicines were being given and recorded safely by the inspection, staffing levels were suitable, risks were assessed, and infection control arrangements were in place. The home had also improved its medicines processes after an earlier medicines error.
Well-led was rated Requires Improvement. The provider's checks had not identified some safeguarding issues or that an incident should have been reported to the CQC. Changes had been made, but inspectors said it was too early to know whether these improvements would last.
Effective, Caring and Responsive were inspected but not rated. Their previous ratings of Good were carried forward because this inspection did not look at all of the evidence needed to review them.
Safe staffing
Inspectors found suitable numbers of staff across the floors and appropriate recruitment checks. The home also had catering and other support staff in place.
“Our review of staff rotas showed that staff were deployed in suitable numbers across each floor of the home.” from the report
Improved medicines safety
Medicines records checked during the inspection were correct, including records for medicines given when needed and controlled drugs. Staff had received medicines training.
“People who used the service now received their medicines safely.” from the report
Kind interactions
People and relatives generally described staff as caring. Inspectors observed staff speaking with people courteously and respectfully.
“We observed interactions between people using the service and staff which were polite, warm and caring.” from the report
Personalised care
Care plans included people's choices and what mattered to them. People and families were involved in care decisions where appropriate.
“People received personalised care and support. People's care plans reflected people's choices, wishes and what was important to them.” from the report
Clean and safe environment
The home was clean and maintained. Fire safety, equipment checks and COVID-19 precautions were in place.
“People were kept safe from fire and other potential hazards, as well as the risks associated with the COVID-19 pandemic.” from the report
Weak oversight and reporting
seriousEarlier internal checks did not identify some safeguarding concerns or that an incident needed to be reported to the CQC. The provider had made changes, but these had not yet been tested over time.
“The provider's monitoring process had had not effectively identified that this incident was notifiable to CQC.” from the report
Medicines disposal records
needs fixingThe pharmacist did not always sign when receiving unused or disposable medicines. The home said it would stress the need for a traceable record.
“However, we found that the pharmacist did not always confirm with their signature when receiving unused or disposable medicines for the service.” from the report
Care information not always current
needs fixingSome dietary and care information did not match or needed updating. Inspectors also found some descriptions of behaviours that needed to be clearer.
“Another person had two sets of guidelines about what type of food consistency they required in the same folder for catering staff to refer to.” from the report
Family communication
minorSome relatives said it was difficult to get a consistent picture of a person's wellbeing. Inspectors raised this with the management team.
“We ring about his well-being and it's hard to get a reliable picture.” from the report
- 01What changes have you made to ensure safeguarding concerns and notifiable incidents are identified and reported promptly?
- 02How do you now check that your audits are finding problems before they are raised by whistleblowers or outside organisations?
- 03How do you make sure unused or disposable medicines are signed for by the pharmacist and have a complete audit trail?
- 04How do you check that dietary instructions, care plans and behaviour guidance are current and consistent in every relevant record?
- 05How will you keep families informed with a clear and consistent update about their relative's wellbeing?
This was a focused inspection of Safe and Well-led, with parts of Effective, Caring and Responsive also examined but not rated; the previous ratings for those three questions were carried forward. This explanation was written from the published report of 5 March 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 2020
Inspected but not rated; inspectors found good infection control and Covid-19 safety measures.
This was an announced, targeted inspection on 10 August 2020. It looked only at infection prevention and control during the coronavirus pandemic.
Inspectors found good practice in admissions, cleaning, personal protective equipment, staff training and risk assessments. They were assured that the home was managing visitors, shielding, social distancing and possible outbreaks safely.
The home was inspected but not rated. This means the report does not provide an overall quality rating, and it does not assess all areas of care.
Safe admissions
New residents were tested for Covid-19 before moving in and completed 14 days of self-isolation. One allocated staff member supported each person during this period.
“The home had an effective admission procedure. All newly admitted people had been tested for Covid19 prior to them coming to live at the home.” from the report
Individual risk assessments
The home assessed the specific infection risks of residents and staff, including the PPE and risk controls needed.
“Each person using the service and staff supporting them had an individualised risk assessment.” from the report
Cleaning arrangements
Extra cleaning staff were used to complete regular cleaning schedules and reduce the risk of cross-infection.
“Strict cleaning regimes helped to protect people and staff from accidental infection cross-contamination.” from the report
Trained staff
Staff were trained about Covid-19 risks, infection control and what to do if symptoms developed. The management team kept staff updated with government guidance.
“Staff were appropriately trained. They understood risks related to Covid19, infection prevention and control measures” from the report
Inspectors raised no specific concerns in this report.
- 01How are new residents tested and supported during any isolation period now?
- 02How are residents' and staff members' individual infection risks assessed and reviewed?
- 03How often are communal areas and frequently touched surfaces cleaned now?
- 04What training do staff receive about infection prevention and control?
- 05How do you manage visitors and possible infection outbreaks?
This was a targeted inspection of infection prevention and control during the coronavirus pandemic; it did not rate the other areas of care. This explanation was written from the published report of 28 August 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 Anne's Nursing Home
5 rated inspections over 7 years: the service has held its Good rating throughout.
- March 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2020Inspected but not ratedSafe: Inspected but not rated
- February 2020Goodstayed GoodSafe: GoodWell-led: Good
- August 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016Goodstayed GoodResponsive: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- December 2014
Registered with the Care Quality Commission on 17 December 2014.
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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