CQC report explained · a nursing home
What the CQC found at St Fillans Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found poor infection-control practices, cleanliness problems and conflicting information in care records. They also found that risk assessments did not always properly reflect choking and mobility risks, although medicines were managed safely and safeguarding systems were in place.
- Effective?
- Requires improvement
- People's care and support was inconsistent. The environment and mealtime experience were poorer in some units, with limited meal choices, delays and staff not always following the home's swallowing-support policy.
- Caring?
- Good
- This question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Responsive?
- Good
- This question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Well-led?
- Requires improvement
- The home had quality checks and an improvement plan, but these had not identified important infection-control, dementia-care and environmental problems. Relatives and staff reported that communication and morale had improved after the new management team arrived.
What inspectors found, November 2022
Requires Improvement; inspectors found infection-control and care-planning risks, although the home acted quickly on some problems.
Inspectors made unannounced visits on 21 and 22 September 2022, followed by a check on 30 September. They observed care, spoke with people, relatives and staff, and reviewed care, medicine, recruitment and management records.
They found poor infection-control practices, including incorrect use and storage of protective equipment, dirty areas and equipment, and kitchens needing cleaning. Care records also contained conflicting information about risks such as choking and moving independently. Some behaviour plans did not give staff enough practical guidance.
The home acted quickly after the first visits. It bought more clinical bins, provided containers for protective equipment, completed a full cleaning programme and carried out spot checks. The follow-up visit confirmed that these actions had been taken, but the home's own checks had not found the problems in the first place.
The overall rating changed from Good in 2018 to Requires Improvement. Safe, Effective and Well-led were rated Requires Improvement. Caring and Responsive were not inspected in this report, so their previous ratings were used when calculating the overall rating.
Quick action on cleanliness
The home acted immediately after inspectors raised infection-control and cleanliness concerns. The follow-up visit confirmed that cleaning and protective-equipment measures had been put in place.
“Our follow up visit on 30 September 2022 confirmed the above action had been taken to prevent the spread of infection and ensure the premises were clean.” from the report
Medicines managed safely
Inspectors found that medicines, including controlled drugs, were managed consistently. Checks against electronic records confirmed that people were receiving medicines as prescribed.
“A random check of people's medicines against the eMAR was carried out and was found to be correct confirming people were receiving their medicines as prescribed, by their GP or other health professionals.” from the report
Access to healthcare
People had access to healthcare when needed, and staff made timely referrals to other professionals. Records showed communication with health professionals and families about people's changing needs.
“The service made appropriate and timely referrals to other relevant professionals and services.” from the report
Improving communication and morale
Relatives and staff said communication and morale had improved after the new management team was introduced. Staff said they felt supported and listened to.
“Staff told us the implementation of the new management team had led to improved morale.” from the report
Infection-control failures
seriousInspectors found problems with protective equipment, clinical waste, dirty bathrooms and equipment, and unclean kitchens. These issues created a risk of infection, although the home took action before the follow-up visit.
“Our visits on 21 and 22 September 2022 found failings in infection control practices and cleanliness of the service.” from the report
Inaccurate risk information
seriousSome records gave conflicting information about swallowing and mobility. This meant staff might not have had the right guidance to prevent choking or pressure wounds.
“We found conflicting information in people's care records which exposed them to the risk of not receiving safe care.” from the report
Behaviour support lacked detail
needs fixingBehaviour plans did not clearly explain what staff should do when people became distressed or anxious. Inspectors also saw little use of meaningful activities to divert people.
“Behaviour support plans did not provide sufficient guidance for staff on how to support people to manage times of distress and anxieties.” from the report
Uneven mealtime support
needs fixingPeople's mealtime experience differed between units. Some people were not offered choices, one person waited 22 minutes for a meal, and staff were seen helping people eat while standing or doing other tasks.
“People were not always being offered a choice of meal or drinks.” from the report
Poorer dementia environment
needs fixingThe Charter unit was less personalised and had a noisy, unsettled atmosphere. Inspectors found limited quiet areas and recommended expert advice about improving the environment for people with dementia.
“There was no clear direction for staff, who were acceptant of people continuously calling out, shouting, and walking up and down the corridors, with minimal attempt to divert them using meaningful activities.” from the report
Checks did not find problems
seriousThe home's audits and governance systems had not identified several of the problems found by inspectors. This meant the provider was not reliably finding and driving the improvements needed.
“Whilst the provider has governance systems in place, these are not always being used effectively to identify and drive the required improvements.” from the report
- 01How have you checked that each person's care records now give consistent and accurate information about choking, swallowing and mobility risks?
- 02What specific instructions are now in each behaviour support plan for helping people who become distressed or anxious?
- 03How do you make sure people in every unit are offered a choice of meals and drinks and receive seated, distraction-free support when eating?
- 04What changes have been made to the Charter unit to provide quieter, more personalised spaces and meaningful activities?
- 05What evidence can you show that your infection-control audits now identify problems with PPE, clinical waste, equipment and kitchen cleanliness?
This was an unannounced focused inspection of Safe, Effective and Well-led, including infection control; Caring and Responsive were not inspected and their previous ratings were carried over. This explanation was written from the published report of 8 November 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.
What inspectors found, April 2018
Rated Good; inspectors found kind, personalised care, but staffing deployment, covert medicines and care records needed further attention.
This was an unannounced inspection on 19 December 2017. Inspectors spoke with people living in the home, relatives, staff and visiting professionals. They observed care and reviewed care records, medicines records, staff files and management systems.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People generally felt safe and described staff as kind, attentive and respectful. The home supported people with dementia, nursing needs, physical disabilities and palliative care.
There had been clear improvements since the September 2016 inspection. Care plans were now personalised, staffing levels had improved, food and mealtime support had improved, and quality checks were more robust. However, inspectors found that staff deployment was not always effective on one unit, some medicines given covertly lacked enough guidance, and some daily care records were not accurate.
Personalised care
Care plans reflected people's physical and emotional needs, choices and preferences. This was a clear improvement from the previous inspection.
“Care plans were written in a person centred manner and reflected the care and support each person required and preferred to meet their assessed physical and emotional needs.” from the report
Kind and respectful staff
Inspectors saw staff being compassionate, attentive and respectful. People were supported with dignity and encouraged to make their own choices.
“Staff were compassionate, attentive and caring in their interactions with people.” from the report
Support with food and health
Food and mealtime support had improved since the previous inspection. People's nutritional needs were assessed and staff involved healthcare professionals when needed.
“Throughout lunchtime staff encouraged people to eat and made sure the mealtime experience was a positive one.” from the report
Activities and inclusion
People could choose from a range of activities, with individual support available for those who preferred not to join group activities.
“This inclusive approach helped to reduce the risk of social isolation.” from the report
Open management
The management team used audits, feedback, complaints and incident reviews to find problems and make improvements.
“The service had a robust quality assurance system and identified shortfalls were addressed.” from the report
Staffing at busy times
needs fixingAlthough staffing levels had improved overall, inspectors found that staff were not always deployed effectively on the Dutch unit, especially around meals and in the evening.
“They need more staff at meal times and in the evenings when they are changing people and need two carers.” from the report
Covert medicines
seriousOne person's medicines were given covertly without advice from a pharmacist. Staff also lacked clear instructions about how the medicines should be prepared and given, creating a potential safety risk.
“There was also a lack of guidance regarding how staff were to administer the medicines.” from the report
Care records
needs fixingDaily records did not always accurately reflect the care provided. Fluid intake records and repositioning charts did not always match people's care plans.
“Further work was needed to ensure that daily records accurately reflected the care and support being given.” from the report
- 01What changes have been made to staff deployment on the Dutch unit during meals and between 5pm and 7pm?
- 02How are covert medicines now reviewed with a pharmacist, and where are the instructions for preparing and giving them recorded?
- 03How do managers check that fluid intake records are accurate for people at risk of dehydration?
- 04How are repositioning records checked against each person's care plan?
- 05How will you involve me and my relative in reviewing the care plan and raising concerns?
This was an unannounced inspection of the overall service, covering all five CQC questions; each area was rated Good. This explanation was written from the published report of 4 April 2018 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 Fillans Care Home
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- November 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- December 2016Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- July 2012
Registered with the Care Quality Commission on 9 July 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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