CQC report explained · a nursing home
What the CQC found at St Gregory's House Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2021
St Gregory's House Limited was inspected but not rated; inspectors were assured that infection control measures were effective.
This was a targeted inspection after concerns about infection prevention and control. An inspector and an infection prevention nurse practitioner visited on 25 January 2021. The visit was announced.
Inspectors found the home clean, tidy and hygienic. Staff used suitable protective equipment, followed hand hygiene practices and had access to regular COVID-19 testing. Staff numbers were monitored.
Inspectors were assured about visitor safety, social distancing, admissions, protective equipment, testing, cleaning, outbreak planning and infection control policies. The home was not given an overall quality rating or a rated judgement for safe care.
Clean environment
The home was clean, uncluttered and tidy. Frequently touched areas were cleaned throughout the day, with detailed cleaning schedules in place.
“The home was visually clean, clutter free and tidy and the staff team kept the home clean and hygienic.” from the report
Good protective equipment practice
Staff had training, suitable protective equipment and well-stocked equipment stations. Inspectors saw staff using protective equipment and practising good hand hygiene.
“All staff were adhering to bare below the elbows, their uniforms were clean and smart, all seen wore appropriate PPE and practised good hand hygiene.” from the report
Staffing and infection support
Staffing levels were monitored, and the provider had increased the number of infection control link staff to support good practice.
“Staff levels were monitored so there were sufficient staff to safely meet people's needs and support them in their recreational activities.” from the report
Pandemic planning and contact
The provider had contingency plans, followed visiting guidance and supported relatives to keep in contact by telephone and electronically.
“The provider had contingency plans in place to promote the safety of the service during the pandemic.” from the report
Inspectors raised no specific concerns in this report.
- 01Has the infection prevention nurse practitioner continued weekly visits, and what did the most recent checks find?
- 02How are frequently touched surfaces and communal areas cleaned now?
- 03How does the home provide and monitor protective equipment, hand hygiene and staff infection control training?
- 04How are relatives currently supported to visit or keep in contact by telephone and electronically?
- 05How does the home arrange COVID-19 testing for residents and staff?
This was a targeted inspection of infection prevention and control measures only; the service was inspected but not rated overall and the other quality areas were not assessed. This explanation was written from the published report of 3 March 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, September 2019
St Gregory's House Limited is rated Good; inspectors found safe, person-centred care, but the well-led rating Requires Improvement.
This was an unannounced focused inspection on 18 and 19 June 2019. Inspectors looked at Safe and Well-led because concerns had been raised about medicines, staffing, falls risks and evening routines.
Inspectors found medicines were given as prescribed and at the right times. They found enough staff, suitable risk plans and regular checks to keep people safe. People said they were happy and had no concerns.
The home had changed its evening routines in February 2019. This gave people more choice about when they went to bed. Inspectors found the care was caring and person-centred.
The overall rating stayed Good. Safe was rated Good, while Well-led remained Requires Improvement because there was not enough evidence to change that rating. Effective, Caring and Responsive were not inspected during this visit, so their previous ratings were carried forward.
Medicines
Inspectors found that medicines were given safely, at the prescribed times, and records matched the stock held.
“Medicines were managed safely and people received them when they should.” from the report
Staffing and safety
There were enough suitably qualified staff to meet people's needs. Staff were present in communal areas and responded to call bells.
“We saw there were adequate numbers of suitably qualified staff to meet people's needs in a timely manner.” from the report
Personal choice
Changes to evening procedures gave people more choice about their bedtime routines and whether they spent time in their rooms.
“These procedures allowed people more choices in ensuring their preferred evening routines were fulfilled.” from the report
Person-centred care
Inspectors found that staff knew people well and put caring values into practice.
“The culture of the service was caring and focused on ensuring people received person-centred care that met their needs.” from the report
Leadership consistency
needs fixingWell-led remained Requires Improvement. A new manager and management structure were in place, but inspectors had not yet seen enough evidence to change the rating.
“At this inspection this key question has remained the same requires improvement. This was because there was not enough evidence to change or amend the current rating.” from the report
- 01What evidence can you show of consistent leadership since this inspection?
- 02What changes have been made to the management structure and how are they monitored?
- 03How do you make sure medicines, including as-required medicines, are given at the prescribed time?
- 04How do you assess and review people's falls and skin integrity risks?
- 05How do you make sure each person's preferred evening and bedtime routine is followed?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 6 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.
Every inspection of St Gregory's House Limited
4 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- September 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2018Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- March 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 14 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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9 live-in carers within about an hour of Westmorland and Furness
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8 can care for a couple. 10 years' experience on average.
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