CQC report explained · a nursing home
What the CQC found at St Catherine's Care Centre Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People sometimes waited a significant time for care. Inspectors also found shortfalls in risk management, medicines, staffing and cleanliness, and identified breaches of Regulation 12 and Regulation 18.
- Effective?
- Good
- This area was not assessed during this focused inspection. The rating from the previous inspection was carried over when calculating the overall rating.
- Caring?
- Good
- This area was not assessed during this focused inspection. People and relatives said staff were kind, caring and understood people's needs.
- Responsive?
- Good
- This area was not assessed during this focused inspection. The report says people's choices could be restricted by staff availability.
- Well-led?
- Requires improvement
- Quality checks did not identify important shortfalls, and feedback from staff, relatives and professionals was not always acted on. This was a breach of Regulation 17.
What inspectors found, December 2023
Rated Requires Improvement; inspectors found delays in care, unsafe medicines and risks that were not always managed.
This was a focused inspection after professionals raised concerns about staffing, moving and handling, cleanliness, medicines and management responses. Inspectors visited on 16 and 17 November 2023. They spoke with people living at the home, relatives, staff and professionals, and checked care records, medicines, recruitment, training and quality checks.
The home did not always have enough staff. People sometimes waited a significant time for help. Risks linked to weight loss and repositioning were not always acted on. Medicines guidance was incomplete, and some areas were not clean. Quality checks had failed to identify several of these problems.
There were also positive findings. People said staff were kind, friendly and respectful. Staff were recruited safely, safeguarding arrangements were understood, and some risks, such as aspiration and diabetes, were managed well. The provider had started a service improvement plan, but the overall rating fell from Good at the last inspection to Requires Improvement.
Kind and respectful staff
People and relatives described staff as kind, friendly, respectful and caring. Staff were also said to understand people's needs and preferences.
“People told us they liked the staff who supported them. They said staff were kind and caring and understood their needs.” from the report
Safe recruitment
Recruitment checks included identity and address checks, references and Disclosure and Barring Service checks.
“The provider's recruitment procedures helped ensure only suitable staff were employed.” from the report
Safeguarding understood
Staff knew how to recognise and report possible abuse and how to escalate concerns if needed.
“People were protected from the risk of abuse because staff attended safeguarding training and were able to describe the signs of potential abuse.” from the report
Some health risks managed well
The home had appropriate guidance for people at risk of aspiration and for people with diabetes. Staff also used recognised tools when people's health deteriorated.
“Other risks were managed effectively. For example, people identified as at risk of aspiration had been referred to a speech and language therapist and guidance put in place” from the report
Improvement plan started
The provider had made a service improvement plan covering communication, training, care plans and risk management.
“The provider had developed a service improvement plan (SIP) in response to concerns raised by professionals in October 2023.” from the report
Not enough staff
seriousPeople sometimes waited a significant time for care. Staff and relatives said staffing levels made it difficult to respond promptly, particularly when two staff were needed.
“There were not always enough staff available to meet people's needs.” from the report
Risks not always acted on
seriousA significant weight loss had not led to documented action. Records also did not show that some people were repositioned as often as their care plans required.
“Risks to people were assessed but not always managed effectively.” from the report
Medicines management
seriousInstructions for some medicines were not detailed enough, and guidance for skin creams was incomplete. The report also refers to a person not receiving a prescribed medicine for eight consecutive days before the inspection.
“Medicines were not always managed safely.” from the report
Cleanliness concerns
seriousSome communal toilets and sluice rooms were not adequately clean, and some bedrooms smelled of urine. Relatives said concerns about cleanliness had not led to enough improvement.
“Standards of hygiene and cleanliness in the home were not adequate.” from the report
Weak quality checks
needs fixingThe home's monitoring systems did not identify staffing, medicines, hygiene, weight loss or repositioning problems. Feedback from some staff and relatives was not acted on.
“Monitoring systems had not identified shortfalls in the delivery of care.” from the report
- 01What staffing levels are now in place on each floor, and how do you make sure people do not wait too long for care?
- 02What action has been taken when people lose weight, and how do you check that repositioning is being recorded correctly?
- 03How have you improved instructions for as-required, variable-dose and skin medicines?
- 04What cleaning changes have been made in bedrooms, communal toilets and sluice rooms, and how are they checked?
- 05Which actions in the service improvement plan have been completed, and what evidence can you show that they are working?
This was a focused inspection of Safe and Well-led only; the other ratings were carried over from the last inspection when calculating the overall rating. This explanation was written from the published report of 19 December 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, March 2022
Rated Good; inspectors found safe, kind and personalised care, with improvements since the previous inspection.
This was an unannounced follow-up inspection on 24 February 2022. Three inspectors visited, spoke with people, relatives and staff, and checked care plans, medicines, recruitment and quality records. Further relatives were contacted by telephone after the visit.
The inspectors found people were safe and that risks, medicines, staffing and infection control were managed. Staff were trained, people were involved in decisions, and their health needs were monitored. People described staff as kind and caring.
Care plans reflected people's choices, communication needs and interests. People had activities, access to healthcare and support to stay in contact with relatives. The home had systems for complaints, audits and learning from incidents.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The previous rating was Requires Improvement, with breaches of regulations. The report says enough improvement had been made and the home was no longer in breach.
People felt safe
People and relatives told inspectors they felt safe. Risks were recorded, reviewed and managed, with extra measures used after incidents such as falls.
“People and relatives told us they felt safe and secure living at St Catherine's Care Centre.” from the report
Kind and respectful care
Staff knew people well, listened to their choices and supported privacy, dignity and independence.
“We observed staff take time to sit and speak with people.” from the report
Personalised support
Care records included people's preferences, histories, interests and communication needs. Staff used this information in daily care and activities.
“People's choices and preferences were reflected throughout their care records.” from the report
Good management oversight
The management team used audits, incident reviews, complaints and feedback to identify and act on improvements.
“Effective systems were in place to monitor the quality of the service provided and address any concerns.” from the report
Night-time waiting
minorSome people said they had waited longer for staff during the night. The registered manager had responded by working a night shift and arranging an additional staff member, and people said this had improved.
“People told us they felt there were sufficient staff although some commented they had to wait longer for staff during the night.” from the report
Use of agency staff
minorThe home was recruiting and using agency staff. The report says the same agency staff were used where possible to support consistency.
“The registered manager told us they were currently recruiting for staff and agency staff were being employed.” from the report
Community links
minorLinks with outside community groups had been difficult during COVID-19 restrictions and were still being re-established.
“Due to COVID-19 restrictions developing partnerships with external community groups had been difficult.” from the report
- 01How many staff are scheduled on each night shift now, and how quickly are call bells answered?
- 02How many agency staff are currently used, and how do you make sure they know each person's care needs and preferences?
- 03What activities and community links are currently available for people who spend much of their time in their rooms?
- 04How are changes in a person's health, weight, falls or medicines reviewed and shared with relatives?
- 05How will you continue checking that care plans reflect people's capacity, choices and end-of-life wishes?
This was an unannounced follow-up inspection covering all five key questions and infection prevention and control, to check improvements after the previous inspection. This explanation was written from the published report of 29 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.
Every inspection of St Catherine's Care Centre Limited
3 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- December 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at St Catherine's Care Centre Limited →
- March 2022Goodup from Requires improvementSafe: GoodWell-led: Good
Read what inspectors found at St Catherine's Care Centre Limited →
- November 2019Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2019
Registered with the Care Quality Commission on 7 February 2019.
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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