CQC report explained · a residential care home
What the CQC found at St Clare's Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2021
Inspected but not rated; inspectors were assured that infection control arrangements were keeping people safe.
This was an unannounced, targeted inspection on 3 December 2020. It looked at infection prevention and control during the coronavirus pandemic.
Inspectors found good arrangements for PPE, testing, cleaning, isolation, visiting and managing possible outbreaks. They were assured that the home was following safe infection prevention and control procedures.
The home was inspected but not rated. This report does not provide an overall quality rating or ratings for the other areas of care.
PPE and testing
Staff had suitable PPE and understood when it needed changing. The home had registered for whole-home testing for staff and residents.
“Staff were provided with the appropriate personal protective equipment [PPE]. Staff were knowledgeable on when to change PPE” from the report
Cleaning and decontamination
The home had cleaning schedules and decontamination processes for bedrooms, shared areas and frequently touched surfaces.
“Cleaning schedules were in place and appropriate decontamination processes were also in place.” from the report
Safe admissions and outbreak planning
People were isolated for 14 days after admission or hospital discharge. The home also had plans for possible further outbreaks and used separate areas and staff teams when needed.
“The registered manager had an admission process in place which minimised the risk of potential transmission of infection to people living at the home.” from the report
Contact with loved ones
The home helped people keep in touch with relatives through video calls and window visits. It had also created a safer area for visits when possible.
“The service had supported people to keep in contact with loved ones including video calls and window visits.” from the report
Inspectors raised no specific concerns in this report.
- 01What arrangements are currently in place for PPE, testing and managing any infection outbreak?
- 02How do you safely admit someone who has recently left hospital or is new to the home?
- 03How can residents currently keep in contact with relatives, and what visiting arrangements are available?
- 04What were the home's previous ratings for caring, effective, responsive and well-led care, as these areas were not assessed in this inspection?
This was a targeted inspection of infection prevention and control only; the service was inspected but not rated. This explanation was written from the published report of 5 January 2021 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, October 2020
Rated Requires Improvement; inspectors found safer medicines and better care planning, but staffing shortages sometimes delayed care.
Inspectors visited on 3 September 2020. They spoke with people, relatives and staff, and checked care records, medicines records, staff files and management records. This was a focused inspection during the COVID-19 pandemic.
The main concern was staffing. The home did not always meet its own staffing levels. Inspectors found that care could be rushed or delayed, including help with personal care and going to the toilet. This was a breach of Regulation 18 about staffing.
Inspectors found improvements in medicines management, risk assessments, care plans and quality checks. People were supported with activities, communication with relatives and end of life choices. Responsive and well-led were rated Good, but Safe remained Requires Improvement, so the overall rating also remained Requires Improvement.
Medicines management
Inspectors found clear improvements in medicines administration, recording, storage and staff competency checks.
“There was good oversight of the staff competence, administration, recording and safe storage of medicines.” from the report
Risk management
People's risks were regularly assessed and staff had up-to-date information about how to reduce those risks.
“The risks to people's safety were regularly assessed, with appropriate measures in place to reduce the risks to people's safety.” from the report
Personalised care planning
Care plans had become more detailed and person-centred. Relatives said staff knew people's preferences and needs.
“At this inspection there had been improvements made to the information in people's care plans to guide staff to provide person centred care.” from the report
Activities and family contact
The home provided daily activities, individual activities and ways for people to stay in touch with relatives during the pandemic.
“They undertook planned activities morning and afternoon every day during the week, and people really enjoyed them.” from the report
Improved oversight
Quality checks had improved and included action plans showing how identified issues would be addressed.
“We saw audits undertaken had identified issues and had action plans in place to show how the issues would be dealt with and by whom.” from the report
Not enough staff
seriousThe home did not consistently meet its own staffing levels. Inspectors found 151 understaffed shifts over 15 weeks, including 87 night shifts.
“Over a fifteen week period 151 shifts had one or more members of staff less than the established number and 87 of these shifts were night duty shifts.” from the report
Delays in care
seriousPeople sometimes had to wait for help, and staff said they could not always complete personal care in the morning.
“People, relatives and staff all told us due to a lack of staff, care was sometimes rushed or delayed for people.” from the report
Personalised care affected by staffing
needs fixingAlthough care planning had improved, staffing shortages sometimes stopped staff from delivering care in line with people's choices.
“The inconsistent staffing levels affected staff's ability to always provide care in a person centred in line with people's choices.” from the report
- 01How many staff are planned for each shift, and how do you make sure the planned staffing level is met?
- 02How do you prevent people waiting for personal care or help to use the toilet when staffing is short?
- 03What action has been taken since the inspection to address the 151 understaffed shifts, including the 87 night shifts?
- 04How can relatives raise concerns if they feel care is rushed or delayed, and how will they be told what action was taken?
- 05How do you check that improved care plans are followed when the home is short-staffed?
This was a focused inspection of Safe, Responsive and Well-led; the ratings for Effective and Caring were not assessed and were carried over from the previous comprehensive inspection. This explanation was written from the published report of 2 October 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 Clare's Care Home
2 rated inspections over a year: the service has held its Requires improvement rating throughout.
- January 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- October 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Good
- August 2019Requires improvementSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2018
Registered with the Care Quality Commission on 1 June 2018.
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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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.