CQC report explained · a nursing home
What the CQC found at St Anselm's Nursing Home
Rated Inadequate: inspectors found the home performing badly and the CQC has taken enforcement action.
What inspectors found, June 2023
St Anselm's Nursing Home was rated Good; inspectors found improved medicines management, safe care and effective leadership.
This was an unannounced focused inspection on 6 June 2023. The inspector spoke with people, relatives, staff and a visiting health professional. They observed care and checked care plans, medicines records, recruitment files and management records.
The home was rated Good for Safe and Well-led. Inspectors found accurate medicines records, enough staff, safe recruitment and guidance for managing risks such as diabetes, anxiety and swallowing difficulties. They also found that accidents were reviewed and action was taken to reduce future risks.
The rating improved from Requires Improvement at the previous inspection. The provider had completed an action plan, and the home was no longer in breach of regulations. However, this inspection only looked at Safe and Well-led. The other areas were not inspected during this visit and their previous ratings were used to calculate the overall rating.
Medicines were managed safely
Medicines records were accurate, staff signed to confirm administration, and storage checks were completed. This was an improvement from the previous two inspections.
“At this inspection, MAR charts were accurate, staff had signed to confirm they had administered people's medicines as prescribed, the number of tablets available matched the number on the MAR chart.” from the report
Risks were assessed
The home had guidance for staff about health risks, including diabetes, distress and swallowing difficulties. Staff followed this guidance when supporting people.
“Potential risks to people's health and welfare had been assessed and there was guidance in place for staff to mitigate risks.” from the report
Enough suitable staff
Inspectors found enough staff to meet people's needs and found that recruitment checks had been completed. Regular agency staff were used to cover nursing shifts when needed.
“There were enough staff to meet people's needs. The number of staff had been calculated according to people's needs.” from the report
Open management
People, relatives and staff said managers were approachable and that concerns could be raised. The home used audits and action plans to address shortfalls.
“Checks and audits had been completed on all areas of the service including infection control, pressure areas and medicines.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you assess whether someone is suitable to share a bedroom, and how are the person and their family involved?
- 02How do you check that medicines records remain accurate and that medicines are given as prescribed?
- 03How do you maintain staffing levels when permanent staff are absent, particularly for nursing shifts?
- 04How are individual risk plans reviewed when someone's health or support needs change?
- 05How are people's views recorded and used to update their care plans?
This was an unannounced focused inspection of Safe and Well-led only; the other key-question ratings were carried forward from the previous inspection. This explanation was written from the published report of 24 June 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, April 2022
St Anselm's Nursing Home is rated Requires Improvement; medicines were not always given safely, although staffing, risk checks and the environment had improved.
This was an unannounced focused inspection on 15 March 2022. One inspector spoke with people, relatives and staff, observed care, and checked care plans, medicines records, recruitment files and management audits.
The home had improved since the previous inspection in 2019. There were enough staff, recruitment checks were safer, the environment was cleaner, and risks, accidents and incidents were being reviewed more effectively.
However, medicines were still not managed safely. Records were inaccurate, staff did not always sign to confirm medicines had been given, and some people had not received medicines as prescribed. The home remained in breach of Regulation 12.
The overall rating remains Requires Improvement. This was the second consecutive inspection with that rating. The Safe and Well-led ratings were Requires Improvement, while the other three ratings were carried forward because they were not inspected.
Enough staff
Inspectors found there were enough staff to meet people's needs. Relatives and staff also said staffing was sufficient.
“There were enough staff to meets people's needs, the number of staff were calculated according to people's needs.” from the report
Improved environment
Washable flooring had replaced carpets in corridors, communal areas and some bedrooms. Inspectors found the previous unpleasant odour was no longer present.
“At this inspection the flooring had been replaced in all these areas with washable vinyl flooring.” from the report
Better risk checks
Environmental risks, equipment checks, accidents and incidents were now recorded and reviewed. The home had taken action when problems were found.
“At this inspection, environmental risk assessments had been reviewed and updated.” from the report
Medicines not always safe
seriousMedicine records were not accurate and staff had not always signed to show medicines were given. Some people had not received medicines as prescribed.
“Medicines administration records (MAR) charts were not accurate, staff had not always signed to confirm medicines had been administered.” from the report
Action had not fixed medicine problems
needs fixingAudits had identified medicine shortfalls, but the same problem was still present two weeks later. CQC required an action plan and said it would check progress.
“The registered manager had spoken to the nurses about the shortfall; however, this had not been effective as the shortfall was still present at the inspection two weeks later.” from the report
- 01What daily checks are now used to make sure every medicine is given as prescribed and recorded correctly?
- 02What happens immediately if a medicine is missed, the record is not signed, or the tablet count is wrong?
- 03How will you show families that the new tablet-counting system has stopped the problems found at the inspection?
- 04Which areas of flooring still need to be replaced, and when will that work be completed?
- 05How are relatives told about medicine errors and the action taken afterwards?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were carried forward from the previous inspection. This explanation was written from the published report of 29 April 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 Anselm's Nursing Home
5 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- June 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- April 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- October 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 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.
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