CQC report explained · a residential care home
What the CQC found at St Heliers Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed, medicines were managed safely, recruitment checks had improved, and infection control arrangements were effective.
- Effective?
- Good
- The report rated this question Good. It describes support with consent, staff training, food, healthcare and people's individual needs, although this was not the main focus of the inspection.
- Caring?
- Good
- No rating was given in this focused report.
- Responsive?
- Good
- No rating was given in this focused report.
- Well-led?
- Requires improvement
- Management had improved and audits were being carried out, but some records were inaccurate or incomplete, the fire risk assessment was out of date, and the manager was not yet registered.
What inspectors found, July 2022
Rated Good overall; safe care had improved, but well-led remained Requires Improvement because some records and checks were not reliable.
This was an unannounced, focused inspection on 9 June 2022. One inspector spoke with people, staff and a relative, observed care, and checked care, medicines, recruitment and management records.
The home had improved since the previous inspection. People said they felt safe and received the care they needed. Risks, medicines, recruitment, infection control and safeguarding were managed safely. Staff supported people with food, healthcare and daily choices.
The main weakness was management oversight. Records about fluid intake and skin care were not always complete or accurate. Some training and supervision were overdue, and the fire risk assessment was out of date. The manager took action, but the well-led rating remained Requires Improvement.
The overall rating changed from Requires Improvement to Good. The home was no longer in breach of the regulations found at the previous inspection. This was a focused inspection, so some ratings were carried forward from earlier inspections.
Improved safety
Inspectors found that risks were identified and managed better than at the previous inspection. The home was no longer in breach of the safety regulation.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 12.” from the report
Safe medicines
People received medicines as prescribed and records showed that medicines were given correctly. Storage, audits and staff competency checks were also in place.
“People received their medicine on time and correctly, as prescribed by their doctor.” from the report
Kind, person-centred care
Staff knew people's preferences and supported them to make choices and remain as independent as possible.
“The manager and staff promoted and encouraged person centred care to ensure people were treated as individuals.” from the report
Improved leadership
A new manager had brought a clearer direction to the home. People, relatives and staff said communication and confidence in the management had improved.
“The quality of service people received had improved since our last inspection.” from the report
Incomplete care records
needs fixingRecords of people's fluid intake and skin care were not always completed fully or consistently. Inspectors said this had not affected people's health at the time, but it was an area needing improvement.
“We found records that monitored people's fluid intake and their skin integrity were not completed consistently and completely by staff.” from the report
Out-of-date fire assessment
needs fixingThe fire risk assessment was out of date. The manager arranged for an external company to update it and put extra safety checks in place.
“The fire risk assessment was out of date.” from the report
Training and supervision delays
needs fixingSome staff training had been delayed and not all staff had received regular formal supervision. The manager had plans to address the shortfall.
“Some staff had received supervisions; however, others had not received regular formal support.” from the report
- 01How do you now check that fluid intake and skin care records are completed accurately every day?
- 02Has the fire risk assessment been updated, and what action was taken after the assessment?
- 03How many staff still have overdue training or supervision, and when will this be completed?
- 04Has the manager's CQC registration been completed?
- 05Have staffing levels increased since the inspection, particularly on shifts where staff said they felt rushed?
This was a focused inspection of Safe and Well-led, including infection control; the report says the other ratings used ratings from earlier inspections. This explanation was written from the published report of 23 July 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, October 2021
St Heliers Care Home was rated Requires Improvement; inspectors found people were cared for kindly, but risks, recruitment and management checks were not reliable enough.
This was an unannounced focused inspection on 4 May 2021. Inspectors spoke with people, staff, a visiting professional and relatives. They reviewed care records, medicines records, staff recruitment files and management checks.
People said they felt safe and were happy with the care. Staff treated people with respect, responded quickly when support was needed and managed medicines safely. Infection prevention arrangements were also found to be effective, apart from minor PPE issues that were corrected straight away.
However, some risk information was incomplete or contradictory. This included guidance about choking, distress, evacuation, weight loss and moving people to protect their skin. Recruitment checks also had gaps, and management systems had not fixed problems found at the previous three inspections.
The overall rating was Requires Improvement. Safe and Well-led were both rated Requires Improvement. The home had remained at this rating for four consecutive inspections.
Kind and respectful care
People were happy with the care and spoke positively about staff. Staff supported people's choices and independence.
“People were happy and content living at St. Heliers Hotel. They were complimentary about the staff and the support and care they received.” from the report
Safe medicines
Medicines were given on time and as prescribed. Records had no gaps or errors, and staff competence was checked regularly.
“Medicines were managed in a safe way. People received their medicine on time and correctly, as prescribed by their doctor.” from the report
Protection from abuse
Staff had safeguarding training and knew how to recognise and report concerns. People told inspectors they felt safe.
“People were protected from harm and the risks of abuse. Staff were trained in safeguarding which helped them to recognise any signs of abuse.” from the report
Communication with families
Relatives were kept updated during the pandemic through newsletters and video-call arrangements. The home also bought equipment to help people stay in contact with family and friends.
“Throughout the pandemic people and their relatives were kept up to date by regular newsletters.” from the report
Learning from incidents
Accidents and incidents were recorded and reviewed. The manager used summaries to look for patterns and prevent repeat events.
“A summary of all accidents and incidents was used to identify any trends and ensure action was taken to prevent reoccurrence.” from the report
Incomplete risk guidance
seriousSome people had risks linked to choking, distress, evacuation, weight loss or skin damage. Care plans and records did not always give clear, individual instructions for staff.
“We found no evidence that people had been harmed however, systems were either not in place or robust enough to demonstrate safety was effectively managed.” from the report
Recruitment checks
seriousInspectors found unexplained employment gaps, incomplete work histories and dates that did not match references. These problems had also been found previously.
“The registered persons had failed to operate a robust recruitment process is a continued breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Weak management oversight
seriousAudits and quality checks had not identified or resolved the same problems found at earlier inspections. There was no action plan showing how the breaches would be corrected and prevented from happening again.
“The registered persons failed to effectively audit, monitor and improve the quality and safety of the service.” from the report
Afternoon staffing concern
needs fixingSome people said there were not always enough staff in the afternoons. The manager was reviewing staffing levels in response.
“Some people told us there was not always enough staff, especially during the afternoons.” from the report
Minor PPE issues
minorInspectors found minor problems with personal protective equipment. These were corrected immediately and had no impact on people.
“Minor issues were identified regarding personal protective equipment (PPE). These were immediately addressed by the registered manager.” from the report
- 01What specific changes have been made to risk plans for choking, distress, evacuation, weight loss and skin protection?
- 02How do you check that staff follow the latest risk guidance consistently?
- 03What recruitment checks are now completed before staff start, including employment gaps, full work histories and references?
- 04What does the condition on your registration require, and what progress has been made against the action plan?
- 05Have afternoon staffing levels changed since the inspection, and how do you check that people receive timely support?
This was a focused inspection mainly covering Safe and Well-led, with infection prevention checks; the report says Effective was reviewed, but only Safe and Well-led received ratings in this report. This explanation was written from the published report of 7 October 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.
Every inspection of St Heliers Care Home
5 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- July 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- July 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- March 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 1 December 2010.
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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