CQC report explained · a nursing home
What the CQC found at St Catherines Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risk assessments, safeguarding procedures, staffing, recruitment checks and medicine systems were found to be effective.
- Effective?
- Good
- People's health, dietary and social needs were assessed and supported. Inspectors found some fluid-monitoring records had not been completed or checked well enough.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People were supported to make choices, stay independent and be involved in their care.
- Responsive?
- Good
- Care plans were detailed and person-centred, and were reviewed when people's needs changed. Activities, complaints handling and communication arrangements met people's needs.
- Well-led?
- Good
- Inspectors found an open, supportive culture, regular quality checks and good teamwork. This rating improved from Requires Improvement at the previous inspection.
What inspectors found, March 2020
Rated Good; inspectors found kind, safe and well-organised care, with some fluid-monitoring records needing improvement.
This was an unannounced planned re-inspection on 4 February 2020. Two inspectors and an Expert by Experience observed daily life, spoke with people, relatives and staff, reviewed care and medicine records, and checked the buildings.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicine systems, suitable training, person-centred care and good support for people's choices, dignity and activities.
There were some gaps in records for people whose fluid intake needed monitoring. Inspectors also noticed unpleasant smells in two rooms. The home was given a recommendation about preventing dehydration, but no regulations were reported as breached.
Kind, person-centred care
People, relatives and staff gave positive feedback about the caring approach. Staff knew people's personalities, needs and preferences.
“There was a strong, visible person-centred culture.” from the report
Enough staff and safe medicines
Inspectors saw staff available to meet people's needs promptly. Medicines were given as prescribed, with staff training and checks in place.
“There were enough staff to keep people safe and meet their needs.” from the report
Good leadership
The home had regular checks, staff meetings and resident meetings. Inspectors found managers and staff worked openly and as a team.
“The service had an open culture.” from the report
Fluid records were incomplete
needs fixingA few records for people needing fluid monitoring were not completed or monitored sufficiently. Two fluid charts did not have a target, so the provider was recommended to consider current dehydration guidance.
“However, we found a few people's records had not been completed appropriately or sufficiently monitored.” from the report
Unpleasant smells in two rooms
minorInspectors noticed malodours in two people's rooms. The manager said the rooms would be discussed with housekeeping and deep cleaned.
“We noted some malodours in two people's rooms and shared this feedback with the registered manager.” from the report
- 01How are fluid charts now completed and checked for people at risk of dehydration?
- 02What training and guidance have staff received about monitoring people's fluid intake?
- 03Have the two rooms mentioned in the report been deep cleaned, and how are any future malodours dealt with?
- 04How will you make sure care records remain accurate when a person's needs change?
- 05What activities are available at weekends, given that one person said there was nothing laid on then?
This was an unannounced planned re-inspection that looked at the overall quality and safety of the care home and rated all five key questions. This explanation was written from the published report of 5 March 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.
What inspectors found, November 2017
St Catherines Nursing Home was rated Good overall, but inspectors found incomplete care records and rated well-led Requires Improvement.
Inspectors visited the home without warning on 2 October 2017. They spoke with people living there, relatives, staff and a visiting health professional. They looked at care plans, medicines records, staff files, the building and records about how the home was run.
The home was rated Good for safe, effective, caring and responsive care. People and relatives generally said they felt safe and were happy with the care. Inspectors found safe medicines arrangements, suitable staffing, trained staff, good health support, respectful care and a range of activities.
The well-led rating was Requires Improvement. Daily records did not always show accurately what care people had received. Audits had not found these gaps, so the provider was still in breach of Regulation 17 on good governance.
The home had improved its staff supervision, appraisals and recruitment checks since the previous inspection. However, the earlier breach about governance had not been fully resolved. The overall Good rating means the home met the required standards in most areas, but its record keeping and checking systems needed improvement.
People felt safe
People and relatives generally said they felt safe. Inspectors found safeguarding procedures, risk assessments and safe handling of people's money.
“People told us they felt safe living at St Catherine's.” from the report
Safe medicines
Inspectors observed medicines being given safely and respectfully. Records, storage and checks for controlled medicines were in place.
“Appropriate arrangements were in place for the safe administration and disposal of medicines.” from the report
Kind and respectful care
Staff knew people well and involved them in choices. Inspectors saw staff protect privacy, ask permission and speak to people respectfully.
“Staff knew people well and positive, caring relationships had been developed.” from the report
Activities and choice
People could choose whether to join activities. The programme included trips, music, games, crafts and individual activities, with provision across all seven days.
“Two activity coordinators were employed to ensure there was a range of meaningful activities on offer every day.” from the report
Improved staff support
Since the previous inspection, staff had received regular supervision and annual appraisals. Recruitment records also contained the required checks.
“We found sufficient improvements had been made to meet the requirements of Regulation 18: Staffing” from the report
Incomplete daily records
seriousSome daily records had gaps about personal care, fluids and oral care. This made it difficult to tell what care had actually been provided and meant the provider could not reliably monitor risks.
“However, some staff were not using the device appropriately or on a frequent enough basis which meant daily records relating to the care and treatment of each person were not fully complete, accurate and up to date.” from the report
Checks had not found the gaps
needs fixingThe home's audits did not identify the missing daily records. Inspectors asked for more frequent and clearer audits, including recording what action was taken when omissions were found.
“However, we found that these audits had not identified the omissions in people's daily care records.” from the report
- 01What changes have you made to ensure daily records of fluids, washing, oral care and other support are complete and accurate?
- 02How often are daily care records now audited, and what happens when a gap is found?
- 03How do you make sure there are enough staff when people need help, and how do you monitor response times to call bells?
- 04Has the dining space been changed since the inspection, and how do you manage tensions or arguments between people?
- 05What evidence can you show that the action taken after the Regulation 17 breach was effective?
This was an unannounced inspection covering all five quality questions and checking improvements after the previous inspection, including the continued governance breach. This explanation was written from the published report of 4 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 Catherines Nursing Home
3 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- March 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- August 2012
Registered with the Care Quality Commission on 21 August 2012.
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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