CQC report explained · a nursing home
What the CQC found at St Faith's Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe, and risks such as falls, choking, pressure damage and weight loss were assessed and reviewed. Medicine systems were not fully reliable, as two people missed some doses and some medicine records had signature gaps.
- Effective?
- Good
- People received support to access health professionals, eat and drink enough, and maintain their health. Staff had training, supervision and support to carry out their roles.
- Caring?
- Good
- People said staff were kind and knew them well. Inspectors saw that privacy, dignity, independence and personal choices were respected.
- Responsive?
- Good
- Care plans were detailed, current and based on people's needs, preferences and life history. People had access to activities, visitors, complaint arrangements and end of life planning.
- Well-led?
- Requires improvement
- The home had approachable managers, an open culture and generally effective quality monitoring. However, medicine monitoring did not identify or escalate missed doses and recording errors quickly enough, and the new arrangements had not been tested long enough for inspectors to judge their effectiveness.
What inspectors found, September 2019
Rated Good overall, but inspectors found medicine monitoring weaknesses and rated the home Requires Improvement for well-led.
Inspectors visited without notice on 20 and 21 June 2019. They spoke with people, relatives and staff, and checked care plans, medicine records, staff recruitment files and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. People said they felt safe, were treated kindly, had their privacy respected and received personalised care. Inspectors also found good support with food, drinks, health care, activities and complaints.
The home was rated Requires Improvement for Well-led. Monitoring did not identify quickly enough that two people had missed some prescribed medicines because they were asleep. There were also gaps in staff signatures on medicine records. Action was taken during and after the inspection, but it was too early to know whether the changes would work.
The overall rating remained Good, the same as at the previous inspection. The home was not placed in special measures in this report. CQC said it would continue to monitor progress and return under its re-inspection programme.
Kind and respectful care
People said staff were caring and knew them well. Inspectors observed respectful communication and support that protected people's dignity and privacy.
“People told us staff were caring and that they knew them well.” from the report
Personalised care planning
Care plans included people's preferences, history, communication needs and support requirements. People or their representatives were involved in planning and reviewing care.
“Care plans were formulated in partnership with those receiving care or, where this was not possible, with people's representatives.” from the report
Health and nutrition support
People could access health professionals and received support with food, drinks and swallowing risks. The home also had staff specifically supporting people at mealtimes.
“The provider employed staff who specifically supported people at mealtimes and with drinks and snacks in-between meals.” from the report
Activities and community links
People could join activities that suited their interests and abilities, or choose not to take part. The home also supported outings and links with community groups.
“People were supported to take part in activities which they enjoyed.” from the report
Medicine monitoring
needs fixingChecks did not identify quickly enough that two people had missed some prescribed medicines because they were asleep. Gaps in staff signatures on medicine records were also not followed up quickly enough to confirm whether doses had been given.
“The process for monitoring the administration of people's medicines had not been effective enough to identify that two people, had not been receiving some of their medicines as prescribed.” from the report
- 01What changes have been made to check that every prescribed medicine is given, including when a person is asleep?
- 02How quickly are missing staff signatures on medicine records now investigated and escalated to senior managers?
- 03How do you check that the medicine policy changes introduced after this inspection are working in practice?
- 04How are people's medicine times adjusted when they do not fit their usual daily routine?
- 05What progress has been made towards improving the Well-led rating since this inspection?
This was an unannounced planned inspection covering all five CQC questions; the previous overall rating was Good, while the Well-led rating fell from Good to Requires Improvement. This explanation was written from the published report of 25 September 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, December 2016
St Faith's Nursing Home was rated Good; inspectors found safe, kind and effective care, with some work still under way to personalise care plans.
This was an unannounced inspection over 18, 19, 20 and 22 August 2016. One inspector spoke with seven people living in the home, five relatives and members of staff. They also reviewed care records, medicines records, complaints, staff files, audits and safeguarding information.
The home was rated Good in all five areas: safe, effective, caring, responsive and well-led. Inspectors found enough staff, safe medicines practices, good training, kind care, suitable activities and a clean, well-maintained building.
At the previous inspection in April 2015, records about care planning, risk assessments, best-interest decisions and staff support were not accurate enough. The report says this breach had been fully met. Care plans were accurate, but further work was under way to make them more personal.
Safe care
Risks such as falls, choking, poor skin condition and poor nutrition were assessed and managed. Inspectors also found safe medicines practices and enough staff to meet people's needs.
“People were protected from abuse, discrimination and poor practice.” from the report
Well-trained staff
Staff received induction, ongoing training, supervision and appraisals. Training covered areas such as dementia, safeguarding, dignity and people's individual health needs.
“People received care and treatment from staff who had received a particularly high standard of training and support.” from the report
Kind and personal care
Staff treated people with compassion and maintained their dignity and privacy. People were supported to stay independent and keep relationships with family and friends.
“People were cared for by staff who were kind and who delivered care in a compassionate way.” from the report
Strong management
The home had clear leadership, good communication and regular checks on quality. The report says these systems had helped the service improve and sustain improvements.
“Robust quality monitoring arrangements were in place which resulted in continued improvement to the service.” from the report
Care plans needed more personal detail
minorCare plans were accurate, but some did not fully put the person at the centre. Work had started to include people's own views and preferences more clearly.
“work had commenced on personalising the care plans.” from the report
Future care planning was not complete
minorThe home wanted to improve discussions about people's future medical and end of life wishes. The report says time for GPs to take part still needed to be arranged.
“Time for their involvement still needed to be planned.” from the report
Some legal safeguard applications were awaiting assessment
needs fixingFour safeguards had been authorised, while numerous other applications had not yet been formally assessed by the responsible local authority body at the time of the inspection.
“numerous other applications had not yet been formally assessed by the supervisory body.” from the report
- 01How will you make sure my relative's care plan records their own words, routines, beliefs and preferences?
- 02What progress has been made with planning people's future medical and end of life wishes?
- 03Are any applications for legal safeguards for my relative still awaiting assessment?
- 04How do you make sure there are enough suitably trained staff on each shift, including when someone is off sick?
- 05How will you involve me in reviewing my relative's care if they cannot take part themselves?
This was an unannounced inspection of the overall service covering all five CQC questions; the report says the previous breach about records had been met. This explanation was written from the published report of 17 December 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of St Faith's Nursing Home
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- September 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 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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