CQC report explained · a nursing home
What the CQC found at St Annes' Community Services - Thornhill Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found safeguarding arrangements, risk assessments, emergency plans, recruitment checks and medicines systems were in place. They also found that the home was clean and medication records were accurate for the controlled drugs checked.
- Effective?
- Good
- Care records reflected people's needs and were kept under review. Staff worked with health professionals, supported nutrition and hydration, and understood the Mental Capacity Act and best-interest decisions.
- Caring?
- Good
- Inspectors saw kind and respectful interactions. Staff knew people's routines and preferences, gave people time to respond, and supported their privacy, dignity and independence.
- Responsive?
- Good
- Care plans included people's needs, preferences and communication methods and were reviewed monthly. People had access to individual activities, easy-read information and detailed end-of-life plans where appropriate.
- Well-led?
- Good
- The home had a positive and inclusive culture. The manager and staff carried out regular quality checks, acted on issues through action plans, and encouraged feedback from relatives, professionals and staff.
What inspectors found, March 2019
Rated Good; inspectors found safe, kind and personalised care across all five areas they assessed.
This was an unannounced, planned comprehensive inspection on 6 March 2019. Two inspectors reviewed information held by the CQC, spoke with staff and a relative, observed daily life, and checked care records, medicines, staff files, the building and quality checks.
Seven people were living at the home, which can support up to seven adults. Some people had limited communication, so inspectors observed how staff responded to people and used feedback from a visiting relative. They found that staff knew people well and provided personalised support.
The home was rated Good in Safe, Effective, Caring, Responsive and Well-led. The report says people were safe, treated with dignity and respect, received care suited to their needs, and benefited from effective management and regular checks.
Personalised support
Staff knew people well and supported their independence, choices and preferences. Care plans gave staff clear guidance about individual needs.
“People received personalised support from staff who knew them well.” from the report
Kind and respectful care
Inspectors observed warm interactions and found that staff respected people's privacy, dignity and communication needs.
“We observed many positive, caring and kind interactions between people and staff.” from the report
Good health support
Staff worked with community health professionals and helped people access dentists, opticians, chiropodists, GPs and specialist services.
“Staff worked with other organisations to deliver effective care and support to people.” from the report
Activities and communication
The home used easy-read information and communication through body language. People were supported with activities such as music, hydro-pool sessions, boat trips and rebound.
“Leisure diaries had been introduced to show how people spent their leisure time.” from the report
Quality monitoring
The manager completed monthly checks and created action plans when improvements were identified. Staff were also involved in quality checks and could raise concerns.
“Each month they completed a range of checks on the service.” from the report
Inspectors raised no specific concerns in this report.
- 01How will staff learn and respond to my relative's individual body language, communication and signs that they may be unwell?
- 02How often will my relative's care plan and risk assessments be reviewed, and how will I be involved?
- 03How will you monitor my relative's medicines, including any medicines taken only when needed?
- 04What activities are available that match my relative's interests, abilities and preferences?
- 05If my relative cannot make a particular decision, how will you record and review the best-interest decision?
This was an unannounced comprehensive inspection covering all five CQC questions, and the care home premises and care provided were both looked at. This explanation was written from the published report of 29 March 2019 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, September 2016
Rated Good; inspectors found safe, kind and personalised care, with only minor uncertainty about how long some improvements could remain outstanding.
This was an unannounced inspection on 16 August 2016. Two inspectors spoke with staff and the manager, observed care, reviewed three people's records, and checked medicines, staffing, training, recruitment and other management records. They also looked around the home and spoke with a relative.
The inspectors rated the home Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. They found enough staff, safe medicines arrangements, suitable training, detailed care plans, respectful care and support for activities, family contact and holidays.
The home was clean, organised and welcoming. There was a complaints process and quality monitoring. The inspectors noted that some improvement actions were being dealt with, but it was not clear how long actions could stay open before being escalated.
Kind, individual care
Staff knew people well and gave support based on their personal needs, preferences and relationships. Inspectors saw people seeking staff out and appearing comfortable with them.
“We found there was a relaxed, friendly and homely atmosphere.” from the report
Safe medicines and risk support
Medicines records were well completed and staff checked medicines carefully before giving them. Risks such as skin damage, nutrition and behaviours that challenged were assessed and managed.
“Medicines were stored appropriately and there were rigorous systems in place to check medicines had been given as prescribed and balances of medicines held were correct.” from the report
Support for active lives
People were supported to take part in activities at home and in the community, visit family and friends, and go on holidays.
“People were supported to live active lives and take part in leisure activities in the home, in the local community and to go on holidays.” from the report
Good care planning
The records reviewed gave detailed information about people's needs, abilities, interests and preferences. Staff used this information to provide personalised support.
“Support records were written in a person centred way and gave specific details which were important to each individual.” from the report
Strong leadership
The home had a relaxed and organised atmosphere. Staff said they felt supported, and the provider used audits and other checks to monitor quality and safety.
“The registered manager led by example and interacted positively with people who lived in the home and staff.” from the report
Unclear escalation of improvement actions
minorThe provider had action plans, but inspectors could not tell how long an outstanding action could remain open before it had to be escalated. This included repainting communal areas.
“However, it wasn't clear how long actions could remain outstanding before they were escalated within the organisation.” from the report
Low survey response
minorThe response to the annual survey of relatives and other stakeholders had been low. Most feedback was positive, and a specific concern had been dealt with.
“The response rate had been low, however, most of the feedback had been positive.” from the report
- 01How many staff are normally on duty during the day and overnight, and how do you cover vacancies or sickness?
- 02How often are improvement actions reviewed, and when are overdue actions escalated?
- 03How will you involve my relative in decisions about activities, family visits and daily routines?
- 04How do you check that staff understand my relative's communication needs, medicines and risk plans?
- 05How do you collect and act on feedback from relatives when survey responses are low?
This was an unannounced inspection covering all five CQC areas and the overall rating; the previous inspection was in May 2014. This explanation was written from the published report of 28 September 2016 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 Annes' Community Services - Thornhill Road
2 rated inspections over 2 years: the service has held its Good rating throughout.
- March 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at St Annes' Community Services - Thornhill Road →
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at St Annes' Community Services - Thornhill Road →
- June 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 15 March 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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